Limitation of Liability (Advance Beneficiary Notice)
Services denied as not reasonable and medically necessary, under Section 1862(a) (1) of the Social Security Act, are subject to the Limitation of Liability (ABN) provision. The ABN is a notice given to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. Providers must complete the ABN and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice.
The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the provider must retain the original notice on file.
Complete instructions and the ABN form (CMS-R-131) can be found on the CMS website.
ABN Modifiers
| Modifier | Description |
|---|---|
| GA | Waiver of liability statement issued, as required by payer policy, individual case |
| GX | Notice of liability issued, voluntary under payer policy |
| GY | Item or service statutorily excluded or does not meet the definition of any Medicare benefit |
| GZ | Item or service expected to be denied as not reasonable and necessary (forgot to issue ABN to patient) Note: All claim line items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review |
For more information on ABNs, you may refer to the CMS MLN Educational Tool®: Advance Beneficiary Notice of Non-Coverage Interactive Tutorial.
Reviewed 9/11/2024