COMPLETING THE ABN
The revised ABN can be found at:
http://www.cms.gov/BNI/02_ABN.asp
The ABN is composed of five sections and 10 blanks, which must appear in the following order from top to bottom on the notice:
Notifier (A)


Patient Name (B)

Identification Number (C)

Body (D)


Table (D, E, F)

o Providers must list the specific items or services believed to be non-covered.

o Providers must explain in beneficiary-friendly language why they believe the items or services may not be covered by Medicare. Commonly used reasons for non-coverage are:



Note: To be a valid ABN, there must be at least one reason applicable to each item or service listed. The same reason for non-coverage may be applied to multiple items.
Estimated Cost (F).
o Provider must complete the Estimated Cost blank to ensure the beneficiary has all available information to make an informed decision about whether to obtain potentially non-covered services.
o Providers must make a good faith effort to insert a reasonable estimate for all the items or services listed. In general, we would expect the estimate be within $100 or 25 percent of the actual costs, whichever is greater. Examples of acceptable estimates would include, but not be limited to the following:

o “Between $150–$300.”
o “No more than $500.”
Multiple items or services that are routinely grouped can be bundled into a single-cost estimate.
Options 1, 2 or 3
The beneficiary or his representative must choose only one of the three options listed.
Option 1:
o This allows the beneficiary to receive the item or services at issue and requires the provider to submit a claim to Medicare. This will result in a payment decision that can be appealed.
Option 2:
o This option allows the beneficiary to receive the non-covered items or services and pay for them out-of-pocket. No claim will be filed and Medicare will not be billed. Therefore, there are no appeal rights associated with this option.
o Providers will not violate mandatory claims submission rules under 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiary’s written request when selecting this option.
Option 3:
o This option means the beneficiary does not want the care in question. By checking this box, the beneficiary understands that no additional care will be provided and, thus, there are no appeal rights.
Additional Information (H)
Providers may use this space to provide additional clarification they believe will be of use to beneficiaries. For example:



o Annotations will be assumed to have been made on the same date as that appearing with the beneficiary’s signature.
Signature Box (I, J)
Once the beneficiary reviews and understands the information contained in the ABN, the Signature Box is to be completed by the beneficiary or representative.
Signature:
o The beneficiary or representative must sign the notice to indicate that he received the notice and understands its contents. If a representative signs, he should indicate “representative” after his signature.
Date:
o The beneficiary or representative must write the date he signed the ABN. If the beneficiary has physical difficultly writing and requests assistance in completing this blank, the date may be inserted by the provider.