If coverage is in question, the DME provider is required to issue a standard notice to the Medicare patient BEFORE providing that item or service. This notice is called an Advance Beneficiary Notice of Non-Coverage or “ABN.” The ABN allows the patient to decide upfront whether or not he or she would like to accept financial responsibility for the item or service, if Medicare does not pay.
The ABN is required in order to bill the patient or his/her co-insurance if Medicare denies coverage. It also serves as proof that the patient knew PRIOR to receiving the item or service that Medicare might not pay.
Medicare coverage criteria can be referenced in the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs):
An ABN must be issued when:
- It is believed that Medicare may not pay for the Medicare covered item or service, or
- Medicare may not consider the covered item to be medically reasonable or necessary