Medicare has broad
coverage, but there are some services that are not covered because they are
considered reasonable, medically necessary, and appropriate. The purpose of the
ABN is to give you the necessary information to make informed decisions about
whether or not to get the services your provider is suggesting.
The following are some examples of when an ABN can be used for non-covered
services:
• Services where there is no legal obligation to pay (e.g., for the
purchase of some vaccines). In those cases, your doctor can charge Medicare for
administering the vaccine, but they cannot charge Medicare for the vaccine.
• Services paid for by a government entity other than Medicare
• Personal comfort items
• Routine eye care
• Dental care
• Routine foot care
ABNs cannot be issued for services that the provider knows is medically necessary
and is covered by Medicare. In addition, an ABN cannot be issued for emergency
ambulance transportation because the patient is presumed to be under ‘great
duress’. An ABN cannot be issued to a patient if they are under great duress.
An ABN must be given to you (or your representative) prior to receiving the
item or service in question. The Centers for Medicare & Medicaid (CMS)
mandates your provider give you the ABN far enough in advance for you to have
time to consider your options and make an informed choice.
CMS has created a standardized ABN form to use; however, it does allow your
health care provider to use their own form, as long as it contains the same
information.
If your provider asks you to sign an ABN, the document must:
• Give the name or description of the service they are providing
• Provide a statement that explains why they believe the services may not
be covered by Railroad Medicare. Some common statements are: 'Medicare does not
pay for this test for your condition,' 'Medicare does not pay for this test as
often as this (denied as too frequent)', or 'Medicare does not pay for
experimental or research tests.'
• Give you the estimated cost of the service or procedure
o Option 1. 'I want the (service or procedure) listed above. You may ask
to be paid now, but I also want Medicare billed for an official decision on
payment, which is sent to me on a Medicare Summary Notice (MSN). I understand
that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to
Medicare by following the directions on the MSN. If Medicare does pay, you will
refund any payments I made to you, less co-pays or deductibles.'
o Option 2. 'I want the (service or procedure) listed above, but do not
bill Medicare. You may ask to be paid now as I am responsible for payment. I
cannot appeal if Medicare is not billed.'
o Option 3. 'I don’t want the (service or procedure) listed above. I
understand with this choice I am not responsible for payment, and I cannot
appeal to see if Medicare would pay.'
The ABN will also have a place for additional information, such as a dated
witness signature.
There must be a place on the ABN for you to sign and date, which indicates you
have reviewed the document and understand the information in it. You cannot
sign the ABN in advance of the rest of the notice.
Some points to remember:
• Just because you sign an ABN does not mean Railroad Medicare will not
pay for the service. Federal law still requires the claim be submitted for
proper review.
• Even if you sign the ABN and Railroad Medicare denies payment, you are
still entitled to appeal the decision. You can pay the provider and later have
your money returned to you from the provider if your appeal is successful.
• If you have a secondary insurance, have the provider submit the claim to
Railroad Medicare for denial. Some secondary insurances may cover services that
Railroad Medicare does not.
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