CMS recently updated their ABN Form and accompanying instructions. For non-participating suppliers that issue an ABN for unassigned items/services you must do the following two things in order for the ABN to be considered a valid notice.
First, in the Options: Blank (G), you must strike the last sentence in the Option 1 paragraph with a single line so that it appears like this:
If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.
This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.
The sentence must be stricken and can’t be entirely concealed or deleted.
Secondly, when the above sentence is stricken in (G), the supplier must include the following CMS-approved unassigned claim statement in the (H) Additional Information section:
“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
This statement can be included on ABNs printed for unassigned items and services or it can be handwritten in a legible 10 point or larger font.
An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice. Similarly, when the unassigned claim statement is included in the “Additional Information” section, the last sentence in Option 1 should be stricken.
To review these instructions, and to access the updated ABN form click here.