To be a valid ABN, there must be at least one reason applicable to each item or service
listed in the column under Blank (D). The same reason for non-coverage may be
applied to multiple items in Blank (D) when appropriate.
6.
Blank (F) Estimated Cost: Notifiers must complete the column under Blank (F) to
ensure the beneficiary has all available information to make an informed decision
about whether or not to obtain potentially non-covered services.
Notifiers must make a good faith effort to insert a reasonable estimate for all of the
items or services listed under Blank (D). In general, we would expect that the estimate
should be within $100 or 25% of the actual costs, whichever is greater; however, an
estimate that exceeds the actual cost substantially would generally still be acceptable,
since the beneficiary would not be harmed if the actual costs were less than predicted.
Multiple items or services that are routinely grouped can be bundled into a single cost
estimate. For example, a single cost estimate can be given for a group of laboratory
tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also
permissible for long term or complex projections. As noted above, providers may also
pre-print a menu of items or services in the column under Blank (D) and include a cost
estimate alongside each item or service. If a situation involves the possibility of
additional tests or procedures (such as in laboratory reflex testing), and the costs
associated with such tests cannot be reasonably estimated by the notifier at the time of
ABN delivery, the notifier may enter the initial cost estimate and indicate the
possibility of further testing. Finally, if for some reason the notifier is unable to
provide a good faith estimate of projected costs at the time of ABN delivery, the
notifier may indicate in the cost estimate area that no cost estimate is available. We
would not expect either of these last two scenarios to be routine or frequent practices,
but the beneficiary would have the option of signing the ABN and accepting liability
in these situations.
7.
Blank (G) Options: Blank (G) contains the following three options:
• OPTION 1. I want the (D) listed above. You may ask to be paid now, but I
also want Medicare billed for an official decision on payment, which is sent to me on a
Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am
responsible for payment, but I can appeal to Medicare by following the directions on
the MSN. If Medicare does pay, you will refund any payments I made to you, less co-
pays or deductibles.
This option allows the beneficiary to receive the items and/or services at issue and
requires the notifier to submit a claim to Medicare. This will result in a payment
decision that can be appealed.