Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 24

For the Week of February 15, 2016-When You Must Issue an ABN

You must issue an ABN when you expect Medicare may deny payment for an item or service because:

It is not considered reasonable and necessary under Medicare Program standards;
The care is considered custodial;
Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception;
A patient is not terminally ill (for hospice providers only); or
A patient is not homebound or there is no need for intermittent skilled nursing care (for home health services only).

Additional mandatory requirements apply to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. An ABN must be issued before DMEPOS suppliers furnish a patient with an item or service that will not be paid for by Medicare because:

The provider violated the prohibition against unsolicited telephone contacts;
The supplier has not met supplier number requirements;
The supplier is a non-contract supplier furnishing an item listed in a competitive bidding area; or
Medicare requires an advance coverage determination, and the patients wants the item or service before the advance coverage determination is made.