Healthcare Provider Solutions

All Medicare and Medicare Advantage beneficiaries and providers have rights and are protected against financial liability through an Advance Beneficiary Notice (ABN). The provider is responsible for giving this notice to the beneficiary in certain instances. The ABN used by hospice providers is Form CMS-R-131 (Exp. 03/2020). This newest version went into effect June 21, 2017. Hospices need to ensure they are using the most current form, which can be found at the following link:  https://www.cms.gov/MEDICARE/medicare-general-information/bni/abn.html

Hospices should complete the ABN and deliver it to the beneficiary in the following circumstances:

  • Prior to providing an item or service that is usually paid for by Medicare but may not be paid for in this particular case because it is not considered medically reasonable and necessary
  • Prior to caring for a patient who is not terminally ill
  • The three situations that would require issuance of the ABN by a hospice are:
    • Ineligibility because the beneficiary is not determined to be “terminally ill”;
    • Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary; or
    • The level of hospice care is determined to be not reasonable or medically necessary, specifically for the management of the terminal illness and/or related conditions.

Following are situations in which an ABN is NOT required:

  • Revocation
  • Respite Care exceeding five consecutive days
  • Transfers
  • Untimely Face to Face Encounter
  • Room and Board for nursing facilities
  • Services unrelated to the terminal diagnosis

When completing this form, it is imperative that in the body of the form at blanks D, E & F the requirements below are followed:

Blank (D) – Descriptors:

  • The notifier must list the specific names of the items or services believed to be noncovered in the column directly under the header of Blank (D).
  • In the case of partial denials, notifiers must list in the column under Blank (D) the excess component(s) of the item or service for which denial is expected.
  • For repetitive or continuous noncovered care, notifiers must specify the frequency and/or duration of the item or service. See § 50.7.1 (b) of the MCPM, Chapter 30 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf) for additional information.
  • General descriptions of specifically grouped supplies are permitted in this column. For example, “wound care supplies” would be a sufficient description of a group of items used to provide this care. An itemized list of each supply is generally not required.

Blank (E) Reason Medicare May Not Pay:

  • In the column under this header, notifiers must explain, in beneficiary friendly language, why they believe the items or services listed in the column under Blank (D) may not be covered by Medicare.
    • Three commonly used reasons for noncoverage 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).”
      • “Medicare does not pay for experimental or research use tests.”
    • To be a valid ABN, there must be at least one reason applicable to each item or service listed in the column under Blank (D). The same reason for noncoverage may be applied to multiple items in Blank (D) when appropriate.

Blank (F) Estimated Cost:

  • Notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services.
  • Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted.

Hospices that have admitted patients under the Medicare or Medicare Advantage payer should not be billed for services that have not been presented to the patient as a liability using the ABN.