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Preview - Advance Beneficiary Notice of Non-coverage Form

 

Name of Practice

 

Letterhead

A. Notifier:

 

B. Patient Name:

C. Identification Number:

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If your insurance doesn’t pay for D.below, you may have to pay.

Your insurance (name of insurance co) may not offer coverage for the following services even though your health care provider advises these services are medically necessary and justified for your diagnoses.

We expect (name of insurance co) may not pay for the D.

 

below.

 

D.

E. Reason Insurnace May Not Pay:

F.Estimated Cost

WHAT YOU NEED TO DO NOW:

Read this notice, so you can make an informed decision about your care.

Ask us any questions that you may have after you finish reading.

 Choose an option below about whether to receive the D.as above.

Note: If you choose Option 1 or 2, we may help you to appeal to your insurance company for coverage

G. OPTIONS: Check only one box. We cannot choose a box for you.

 

☐ OPTION 1. I want the D.

 

listed above. You may ask to be paid now, but I also want

 

 

 

my insurance billed for an official decision on payment, which is sent to me as an Explanation of

 

Benefits. I understand that if my insurance doesn’t pay, I am responsible for payment, but I can appeal

 

to __(insurance co name)____. If _(insurance co name_ does pay, you will refund any payments I

 

made to you, less co-pays or deductibles.

 

 

 

 

☐ OPTION 2. I want the D.

 

 

listed above, but do not bill (insurance co name). You

 

 

 

 

may ask to be paid now as I am responsible for payment

 

☐ OPTION 3. I don’t want the D.

 

 

 

listed above. I understand with this choice I am not

 

 

 

 

 

responsible for payment.

 

 

 

H. Additional Information:

 

 

 

This notice gives our opinion, not a denial from your insurance company. If you have other questions on this notice please ask the front desk person, the billing person, or the physician before you sign below.

Signing below means that you have received and understand this notice. You also receive a copy.

 

I. Signature:

J. Date:

 

 

 

 

 

 

October 2016 revision

⇓ Advance Beneficiary Notice of Non-coverage PDF

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Similar forms

  • Notice of Exclusion from Medicare Benefits (NEMB): This document informs beneficiaries that a specific service or item is not covered by Medicare, similar to how the Advance Beneficiary Notice of Non-coverage (ABN) indicates potential non-coverage for a service.
  • General Power of Attorney Form: To authorize decision-making in financial matters, refer to our comprehensive General Power of Attorney form for clear guidance on delegation of authority.
  • Medicare Summary Notice (MSN): The MSN provides a summary of services received and explains what Medicare paid, what the beneficiary owes, and any services not covered, paralleling the ABN's purpose of clarifying coverage issues.
  • Patient Financial Responsibility Agreement: This agreement outlines the costs a patient must pay for services not covered by insurance, similar to the ABN, which alerts beneficiaries to potential out-of-pocket expenses.
  • Consent for Treatment Form: This form is used to obtain patient consent before providing services, similar to the ABN in that it ensures patients are informed about what they are agreeing to, particularly regarding coverage.
  • Medicare Enrollment Form: This document is used for enrolling in Medicare and includes information about coverage options, akin to the ABN's role in informing beneficiaries about their coverage status.
  • Explanation of Benefits (EOB): The EOB details the services provided, what was covered, and what the patient must pay, mirroring the ABN's function of clarifying coverage and financial responsibility.
  • Prior Authorization Request: This document is submitted to obtain approval for certain services before they are provided, similar to the ABN in that it addresses coverage issues before services are rendered.
  • Out-of-Pocket Cost Estimate: This estimate provides a breakdown of expected costs for medical services, paralleling the ABN by giving beneficiaries a clear understanding of potential financial responsibilities.