Brad Esarey, Vice President of Sales Leading with Compliance:
The Advanced Beneficiary Notice (ABN) Form
Slide 2
Agenda What is the ABN Form? What does it do? Who is it for?
Why do you need to fill out the form? How do you fill out the
form?
Slide 3
The Advanced Beneficiary Notice (ABN) is documentation that
assures Medicare patients have been fully informed of their
responsibility to pay for tests ordered but not routinely
reimbursed by Medicare. It is a legal requirement for people
enrolled in original, fee-for- service Medicare. What is the ABN
Form?
Slide 4
The ABN enables the beneficiary to make an informed decision
about whether to order services and accept financial responsibility
for those services if Medicare does not pay. The ABN serves as
proof that the beneficiary knew prior to getting the service that
Medicare might not pay. If you do not issue a valid ABN to the
beneficiary when Medicare requires, you cannot bill the beneficiary
for the service and you may be financially liable. What does the
ABN do?
Slide 5
The ABN is for Medicare patients only. The Advance Beneficiary
Notice (ABN) is only administered to MEDICARE beneficiaries. It is
a written notice that the Ordering Physician or healthcare provider
gives to a Medicare Beneficiary. Who is the form for?
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CYP2C9 VKORC1 CYP1A2 CYP3A4 CYP3A5 SULT4A1 SLC6A4 (Serotonin
Transporter) SLCO1B1 OPRM1 The ABN is required for the following
tests:
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A properly executed ABN is required to allow PGXL Laboratories
to bill the patient. The ABN must be signed before the sample is
collected. Why do you need to fill out the form?
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1.Use the most current version of The Advanced Beneficiary
Notice of Noncoverage (ABN), Form CMS-R-131(03/11) 2.Complete the
ABN in pen by providing the required information in the spaces
provided on the form. a. Patients full name as it appears on his or
her Medicare Card b. Medicare Number (HICN number) c. Complete the
reason you expect Medicare to deny the claim by writing the test
name in the appropriate column i. Medical Necessity ii. Frequency
Limitations iii. Experimental or research test d. Estimate the
laboratory cost using the PGXL LIST fee schedule e. Allow the
patient to select one of the following options How to fill out the
form
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OPTION 1: I want the D. (name of test) 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.
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OPTION 2: I want the D. (name of test) 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.
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OPTION 3: I don't want the D. (name of test) listed above. I
understand with this choice I am not responsible for payment, and I
cannot appeal to see if Medicare would pay.
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PGXL Laboratories will not report or bill any test in the above
list that does not have a fully correct and executed ABN.
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PGXL will send the patient two bills. PGXL expects the patient
to pay the balance that is due for the testing provided. The price
list for each test is on www.pgxlab.com/abn. Patient
Responsibility
Slide 14
The ABN policy will take full effect as of October 1, 2013.
PGXL will use the next 45 days, to notify EM of instances that fall
short of the policy, so the field is ready for the go-live
date.
