Oncology & Hematology Coding Alert

Question: How do I know whether I’m using the correct advanced beneficiary notice (ABN) form for patients?

Delaware Subscriber

Answer: The correct form for use on and after Jan. 1, 2021, reads “Form CMS-R-131 (Exp. 06/30/2023).” The Centers for Medicare & Medicaid Services (CMS) now offers additional guidelines for patients who are covered by both Medicare and Medicaid, which are known as dually eligible beneficiaries. These patients cannot be charged for Medicare cost-sharing when they receive services under Medicare Part A or Part B.

CMS updated the ABN form and guidelines to solidify the fact that providers cannot bill dually eligible beneficiaries when the ABN is furnished.

“Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” the new ABN guidelines state. “Strike through Option Box 1 as provided below:”

• OPTION 1. I want the (D) listed above. I want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN).

CMS is specific in its wording. “Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” CMS says in the ABN instructions. “If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.

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.”

Don’t forget that you must provide the patient with a copy of the signed ABN, and you should keep the original ABN on file.

Resource: To access the new ABN form and the latest instructions, visit: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.