Regulation Surrounding the Update
CMS announced that the Advanced Beneficiary Notice (ABN), Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The new ABN form is effective for use on or after August 31, 2020, with an expiration date of June 30, 2023. Home Health and Hospice Providers need to ensure they are using the most current form, located at the following link: https://www.cms.gov/MEDICARE/medicare-general-information/bni/abn.html
All Medicare Beneficiaries and Healthcare Providers have rights and are protected against financial liability through an Advanced Beneficiary Notice (ABN). Home Health providing care under Part A or Part B and Hospice providers under Part A are responsible for giving this notice to the beneficiary in situations where Medicare payment is expected to be denied. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).
Specific Instructions for Completion
The ABN Form CMS-R-131, is issued by Medicare Home Health and Hospice providers to notify the beneficiary that Medicare may not or will not pay for an item and/or service and informs the beneficiary of potential financial liability, should the patient agree to continue with the service. Reviewing the ABN with the beneficiary is necessary and should be delivered in enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.
Special instructions apply when a provider issues an ABN to a Dually Eligible Beneficiary enrolled in BOTH Medicare and Medicaid, based on the expectation that Medicare will deny the item or service because it is not medically reasonable and necessary or constitutes custodial care.
- The provider cannot bill the dually eligible beneficiary when the ABN is furnished.
- Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:
- If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
- If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any State laws that limit beneficiary liability.
- Dually Eligible Beneficiaries MUST be instructed to check Option Box 1 on the ABN form with the following modification in order for a claim to be submitted for Medicare adjudication.
When or When NOT to Issue the ABN
Hospice Providers should only use the ABN in the following circumstances:
- Prior to providing an item or service that is usually paid for by Medicare but may not be paid for 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 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.
An ABN should NOT be issued in Hospice for:
- Respite Care Exceeding 5 Consecutive Days
- Untimely Face to Face Encounter
- Room and Board for Nursing Facilities or
- Services Unrelated to the Terminal Diagnosis
Home Health Providers should use the ABN in the following circumstances:
The Home Health agency has reason to believe Medicare will not pay for the service due to:
- Services not medically reasonable and necessary
- Services are for custodial care only
- The patient is not homebound
- The intermittent requirements are not met
Healthcare Provider Solutions is dedicated to providing the Home Health and Hospice industries with the education and resources necessary to keep you performing at the highest level of success. If we can assist you in any way, please don’t hesitate to contact us.