ABN: A Brief Refresher

Short for Advance Beneficiary Notice of Noncoverage, an ABN is given to a Medicare beneficiary when services furnished are believed to be partially or entirely non-covered. Its use is mandatory in a limited number of scenarios, optional in others, and inappropriate in emergency situations, or when a patient may be under duress.

Does it Pass the Test?
When unsure if an ABN should be used, it helps to ask the following three questions. If all criteria are met, an ABN must be used.
  • Is the service typically a covered ambulance benefit?
  • Will payment for part or all of the service be denied because it is not reasonable and necessary in this particular instance?
  • Is the patient stable and the transport non-emergent?
Voluntary Use
Many ambulance services find it useful to issue an ABN in certain optional scenarios, in part because it can help the patient better understand his or her financial responsibility. Typically, these include:
  • Non-medically necessary transports
  • Transport to a doctor’s office or other non-covered destination
  • Wheelchair van or stretcher van transports
  • Excess mileage
  • Convenience transports
In either mandatory or voluntary usage, an ABN should be issued prior to the delivery of the service in question. With that stated, let’s consider a couple scenarios to help put this in context:

Scenario 1
A beneficiary requires ambulance transportation from a SNF to dialysis, but demands to be taken to a new dialysis center 20 miles beyond the nearest facility. Medicare covers this type of transport; however, since this particular transport is not to the nearest facility, it is not considered a covered Medicare benefit. Therefore, an ABN is not required. As a courtesy to the beneficiary, an ABN could be issued to help him or her better understand his or her financial responsibility. Also, it is worth noting that, in non-emergency situations, an ambulance service may collect non-covered mileage charges prior to transport.

Scenario 2
A beneficiary requires non-emergent ground transport from a local hospital to the nearest tertiary hospital facility; however, the patient’s family wants him taken by air ambulance. The ambulance service is a covered benefit, but the higher level of aeromedical care is not reasonable and necessary for the patient’s current condition. Because of this, an ABN is required prior to providing the service.

Remember that the issuance of an ABN is mandatory only when a beneficiary’s covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs.

On the other hand, if an ambulance transport (or part of one) is statutorily excluded from coverage because it fails to meet Medicare’s definition of the ambulance benefit (which is the case with our first scenario), an ABN is not mandatory. In these cases, a voluntary ABN may be issued as a courtesy.

Finally, to reiterate what we mentioned earlier, it is inappropriate to issue an ABN during an emergency, or when a patient is under duress. An ABN is a form which shifts financial responsibility to a patient, and a patient who may be under duress is not in the proper state of mind to make any such determination.
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