Medicare Part B advance beneficiary notices
Medicare Part B allows coverage for services and items deemed medically reasonable and necessary for treatment and diagnosis of the patient.
For some services, to ensure that payment is made only for medically necessary services or items, coverage may be limited based on one or more of the following factors (this list is not inclusive):
?? Coverage for a service or item may be allowed only for specific diagnoses/conditions. Always code to the highest level of specificity.
?? Coverage for a service or item may be allowed only when documentation supports the medical need for the service or item.
?? Coverage for a service or item may be allowed only when its frequency is within the accepted standards of medical practice (i.e., a specified number of services in a specified timeframe for which the service may be covered).
If the provider believes that the service or item may not be covered as medically reasonable and necessary, the patient must be given an acceptable advance notice of Medicare’s possible denial of payment if the provider does not want to accept financial responsibility for the service or item. Advance beneficiary notices (ABNs) advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment.
Patient liability notice
The Centers for Medicare & Medicaid Services’ (CMS) has developed the Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131), formerly the “Advance Beneficiary Notice.” Section 50 of the Medicare Claims Processing Manual provides instructions regarding the notice that these providers issue to beneficiaries in advance of initiating, reducing, or terminating what they believe to be noncovered items or services. The ABN must meet all of the standards found in Chapter 30. Beginning March 1, 2009, the ABN-G and ABN-L was no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131). Section 50 of the Medicare Claims Processing Manual is available at http:// www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/ clm104c30. pdf#page=44.
Reproducible copies of Form CMS-R-131 ABNs (in English and Spanish) and other BNI information may be found at http://www.cms.gov/ Medicare/Medicare- General-Information/ BNI/index.html. ABN modifiers
When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item. Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item. Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.
Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.