How to Complete the ABN Form

June 15, 2015
Rick Gawenda

The past 2 weeks, I wrote on 2 primary reasons why a provider may have to issue an advance beneficiary notice of noncoverage (ABN) to a Medicare beneficiary receiving outpatient therapy services. In this week’s article, I am going to teach providers how to complete the ABN form and provide examples of completed ABN forms.

The Centers for Medicare and Medicaid Services (CMS) has an ABN form, CMS-R-131, on their website that suppliers and providers can use to notify Medicare beneficiaries of expected noncoverage of a service or services provided. If suppliers and providers wish to, they can develop their own equivalent of the ABN form; however, it must be produced on a single page in either letter or legal size and contain all the required fields and information as is on the CMS ABN form.

The CMS ABN form is comprised of 10 blanks, labeled A through J, that must be completed in order for the ABN to be considered valid. I will now explain what information must go in each of the 10 fields and at the end of this article, provide an example of a completed ABN form for outpatient therapy services. To view the entire article, log in or become a Gold Member now.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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