Medicare Coverage of Chiropractic Services

Advance Beneficiary Notice of Noncoverage Liability

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a standardized notice that a health care provider/supplier or his/her designee must give to a Medicare beneficiary before providing certain Medicare Part B (outpatient) or Part A (limited to hospice and religious nonmedical health care institutions only) items or services. The ABN must be issued when the health care provider believes that Medicare may not pay for an item or service that Medicare usually covers because it is not considered medically reasonable and necessary for this patient in this particular instance.

ABNs are only provided to beneficiaries enrolled in original (i.e., Fee-for-Service [FFS]) Medicare. The ABN allows the beneficiary to make an informed decision about whether to receive services and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof that the beneficiary had knowledge prior to receiving the service that Medicare might not pay. If a health care provider/supplier does not deliver a valid ABN to the beneficiary when required by statute, the beneficiary cannot be billed for the service and the provider may be held financially liable.

The ABN also serves as an optional notice that providers/suppliers may use to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers. ABN issuance is not required in order to bill a beneficiary for an item or service that is not a Medicare benefit and thus, never covered.

For more information and instructions on the ABN, see the MLN Booklet^®: Medicare Advance Written Notices of Noncoverage. The ABN Form CMS-R-131 and instructions are located at Beneficiary Notices Initiative (BNI).

Answers to Common ABN Questions

If the beneficiary is not the person signing the ABN, does the person who signs it have to put their relationship to the beneficiary in parentheses on the form?

Answer: The beneficiary (or representative) should sign the notice to indicate that he or she has received the notice and understands its contents. If a representative signs on behalf of a beneficiary, he or she should sign his or her own name and write out “representative” in parentheses after his or her signature. The representative’s name should be clearly legible or noted in print.
How long does a beneficiary have to change his or her mind after filling out and signing the ABN form?

Answer: A single ABN is valid for up to one year; thus, the beneficiary would have up to one year to change his/her option selection on the ABN.
What assistance could a notifier provide to a patient if they are unable to sign the ABN themselves? Would the notifier need to document that they assisted the beneficiary with signing the document?

Answer: If the beneficiary is unable to sign the ABN, the notifier should present the ABN to someone who is authorized to sign on the beneficiary’s behalf. For purposes of signing the ABN on the beneficiary’s behalf, an authorized representative should have no relevant conflict of interest with the beneficiary. Therefore, a notifier (including the notifier’s employees) that has a conflicting interest (such as shifting financial liability to the beneficiary) is not qualified to be an authorized representative. However, if the caregiver at a nursing facility where the beneficiary resides is not the notifier (or notifier’s employee) and the caregiver has been authorized by the beneficiary or the beneficiary’s legal representative, the caregiver may sign the ABN.
Please specify what is considered an “authorized representative.” Is the representative required to have POA?

Answer: The authorized representative is not required to have power of attorney. The representative signing the ABN must sign his or her own name, followed by the word “representative.”

An authorized representative should have the beneficiary’s best interests at heart and should be reasonably expected to act in a manner which is protective of the person and the rights of the beneficiary. In the absence of some more compelling consideration, the order of priority of authorized representatives is:

the spouse, unless legally separated.
an adult child.
a parent.
an adult sibling.
a close friend (defined as “an adult who has exhibited special care and concern for the beneficiary, who is familiar with the beneficiary’s personal values and who is reasonably available”).

An authorized representative should have no relevant conflict of interests with the beneficiary. A notifier (including the notifier’s employees) that has a conflicting interest (such as shifting financial liability to the beneficiary) is not qualified to be an authorized representative.

Is it proper to use a company logo in section A of the ABN?

Answer: Yes. Section A must contain the name and address of the notifier. According to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.6.3 Paragraph A:

“Blank (A) Notifier(s): Notifier must place their name, address and telephone number (including TTY number when needed) at the top of the notice. This information may be incorporated into a notifier’s logo at the top of the notice by typing, hand-writing, preprinting, using a label or other means.”
When you enter the cost estimate in Section F of the ABN, should you use the Medicare allowed amount or is there another formula that should be used?

Answer: The amount indicated in blank F should reflect the actual amount of charge to the beneficiary. This is to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services. The provider must make an effort to insert a reasonable estimate for all of the items or services listed in Blank D. Medicare expects the estimate to be within $100 or 25% of the actual costs, whichever is greater. Please reference the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.6.3.
When the beneficiary has an insurance that is primary to Medicare, does the provider still need to issue an ABN when the provider thinks the service may not be covered by Medicare?

Answer: Yes. The ABN must be executed whether Medicare is the primary, secondary, or tertiary payer. In some cases the primary insurer will cover the charges, so make sure that the patient understands that Medicare will not pick up any unpaid balance left by the primary insurer.
In the event the beneficiary refused to complete or sign an ABN, who qualifies as a second party witness? Can other office staff be a witness?

Answer: A member of staff can witness the event. It can also be a family member or anyone who accompanies the patient to the facility. However, according to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.6.3, the witness is not required.
Would an electronic ABN with an electronically collected signature be acceptable?

Answer: The signed hard copy of the ABN may be scanned for retention by the provider and the hard copy given to the beneficiary. CMS currently does not have a policy to allow for electronic issuance and signatures for the ABN.

Revised 9/11/2024