by abilling, August 1, 2017

When filling out and giving your patients an ABN to sign for services you believe may be denied by Medicare, please be sure the ABN is filled out correctly.  If it is not filled out correctly, it will cause the ABN to be void and invalid.  Here are special instructions which must be followed to consider the form valid with Medicare:



Blank (A) Notifier(s): Notifiers must place their name, address, and telephone number at the top of the notice.

Blank (B) Patient Name: Notifiers must enter the first and last name of the beneficiary receiving the notice, and a middle initial should also be used if there is one on the beneficiary’s Medicare card.

Blank (C) Identification Number: Use of this field is optional.




Blank (D): The notifier must list the specific items or services believed to be noncovered .

Blank (E) Reason Medicare May Not Pay: Notifiers must explain, in beneficiary friendly language, why they believe the items or services described in Blank (D) may not be covered by Medicare.

Blank (F) Estimated Cost: Notifiers must complete Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services.

  • “Between $xxx-xxx”
  • “No more than $xxx”




Blank (G) Options: The beneficiary or his or her representative must choose only one of the three options listed. Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.

  1. Additional Information

Blank (H) Additional Information: Notifiers may use this space to provide additional clarification that they believe will be of use to beneficiaries.

  1. Signature Box

Blank (I) Signature: The beneficiary (or representative) must sign the notice.

Blank (J) Date: The beneficiary (or representative) must write the date he or she signed the ABN



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abinsights readers are invited to submit comments, questions, tips, and suggestions for articles on any subject related to billing, collections, coding, reimbursement, and compliance.  Send to:  Anesthesia Billing, Inc.,     P O Box 388, Newton, KS  67114-0388.  Phone 316-281-3700.  Fax 316-282-4322.

Our purpose is to help you meet inevitable challenges.  We hope to deliver practical knowledge and solutions drawn from top resources and business publications in every issue, knowledge you can use today.

Reasonable attempts have been made to be accurate.  However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ.  Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations.  For information specific to your practice, consult a qualified professional.

The information included in this publication is provided, among other things, to alert you to legal developments and should not be considered legal advice.  Specific questions about how this information affects your particular situation should be addressed to your attorney.

Editor:  Philip Blann (

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