CMS-R-131 Comment #17

University of Michigan
Hos~itelsand Health Centers

University of Michigan Health Centers Financial Services
Division
Billing and Third Party Collections
3621 S. State Street
700 KMS Place
Ann Arbor, MI 48108-1652
Phone: 734-764-3150

CMS Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Attention:
Bonnie Harkless
Room C4-26-05
7500 Security Blvd
Baltimore, MD 21244- 1850
April 9, 2007
Re:

Public Comment Advance Beneficiary Notification of Non-coverage

Dear Bonnie,
Based upon the wording of the revised ABN, the University of Michigan Hospitals and Health
Centers is concerned with the elimination of the use of the Notice of Exclusion from Medicare
Benefits (NEMB) and the potential impact for patients and departments within the health system.
While the NEMB is not required to be issued for excluded services, its purpose was to protect
facilities by informing the patient of excluded benefits and the cost associated. As you are aware
the NEMB currently list some excluded services.
According to the Form Instructions OMB Approval Number: 0938-0566; the section which
covers when the ABN is delivered states; "This new version of the ABN must also be used in
place of the Notice of Exclusion from Medicare Benefits (NEMB) to provide voluntarily
notification of financial liability". It is unclear if the intent is to require Providers to issue the
new ABN to all patients receiving excluded services.
Since it was not a previous requirement to issue an NEMB for excluded services, change in this
Policy will place an undo burden upon Providers rendering excluded services.
Please provide direction and clarity to the intent of replacing the NEMB form with the new
combined ABN.
Thank you,

Darryl E. Campbell
Financial Senior Manager
Enclosure (1)
I

Page 1 of 1

Form Instructions
Advance Beneficiary Notice of Noncoverage (ABN)
OMB Approval Number: 0938-0566
Physicians, providers (including institutional providers like outpatient hospitals),
practitioners and suppliers paid under Part B, as well as hospice providers paid
exclusively under Part A (hereinafter "the notifier"), must complete the ABN as
described below, and deliver the notice to the affected beneficiary 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 their representative and any questions raise
during that review must be answered before they sign it. 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, the notifier retains the
original notice on file, and gives a copy to the beneficiary or representative. (Note that
other Medicare institutional providers paid under Part A use other approved notices for
this purpose.)

When the ABN is Delivered
This version of the ABN combines the former ABN-G and former ABN-L into a single
notice. Previously, the ABN was only required for denial reasons recognized under
section 1879 of the Act. This version of the ABN must also be used in place of the
Notice of Exclusion from Medicare Benefits (NEMB) to provide voluntarily notification
of financial liability Employees or subcontractors of the notifier may deliver the ABN,
but the notifier remains responsible for both proper delivery of the notice and retaining
the original notice on file.

Completing the Notice
OMB-approved ABNs are placed on the CMS website at: http:Nwww.cms.hhs.gov .
Notices placed on this site can be downloaded and must be used as is. Additionally,
ABNs must be reproduced as a single page document. The page may be either letter or
legal-size, with additional space allowed for each blank needing completion when a
legal-size page is used.

Sections and Blanks:
There are 10 blanks for completion in this notice, subdivided into five parts in the
following order on the page, from top to bottom: the header, body, option box,
other insurance and signature box. Blanks (A)-(F) may be completed prior to
delivering the notice. Entries in the blanks may be typed or hand-written, but
should be large enough (i.e., approximately 12-point font) to allow ease in
reading. The Option Box, Blank (G), as well as other insurance, Blank (H), must
be completed by the beneficiary or hisher representative. Blank (I) should be a
cursive signature, with printed annotation if needed in order to be understood.

Header
Blank (A) Supplier /Provider:
Notifiers may elect to place their logo at the top of the notice. At a minimum, the
name, address, and telephone number (including TTY) of the notifier must
appear, whether incorporated into the logo or not, to ensure the beneficiary's
ability to follow-up with additional questions. The title for Blank (A) may be
completely removed during reproduction so that the entire top of the notice above
Blank (B) is clear to accommodate letterhead type logos that go across the entire
Page.
Blank (B) Beneficiary Name:
Notifiers must enter the first and last name of the beneficiary receiving the notice,
and middle namelinitial also if used on the beneficiary's Medicare (HICN) card.
Blank (C) Identification Number:
Notifiers should enter an identification number for the beneficiary that helps to
link the notice with a related claim when applicable. When a number such as a
Medicare number or HICN is used, the notice must be delivered in a secure
manner consistent with federal privacy requirements.
Body
Gridlines appear across all 3 blanks in this section of the notice so that when there are
multiple items or services at issue, the name of each item or service, the reason it is not
covered by Medicare and the estimated cost are all parallel. This will ensure that the
beneficiary or representative understands which reasons and costs match particular items
or services. It is permissible for multiple items or services to all be explained by one
reason or bundled under one cost, in which case the same information would not have to
be entered multiple times. The ABN allows for entry of up to 6 items or services. If
more items or services need to be described, another ABN should be used. Notifiers may
also place a single entry on multiple lines (e.g., a single item may be described across the
first two rows of Blanks (D)-(F)).
Blank (D) Items(s)/Service(s):
Notifiers must enter the nameldescription of all item(s) and/or service(s) that are
the subject of the notice. Whenever possible, language that is easy for
beneficiaries to understand should be used. If technical language must be used, it
must be explained verbally to the beneficiary or representative. It is never
permissible to add items or services to Blank (D) after the beneficiary or
representative has signed the notice. The ABN is only effective for items and
services clearly described on the notice at the time it is signed by the beneficiary
or representative.
Blank (E) Reason:

In this blank, notifiers must explain, in beneficiary-friendly language, why they
believe the care that is the subject of the notice is not covered by Medicare. For
example, in the previous version of the ABN-L, there were 3 possible reasons for
noncoverage pre-printed on the ABN:
"Medicare does not pay for these tests for your condition"
"Medicare does not pay for these test as often as this (denied as too frequent)"
"Medicare does not pay for experimental or research use tests"
These reasons are still appropriate for use in Blank (E) of this ABN.

Blank (F) Estimated Cost:
Notifiers must enter a cost estimate in this blank for the items or services
described in Blank (D).
Option Box
Blank ( G )Options:
These 3 checkboxes represent the beneficiary's possible choices regarding the
potentially noncovered care described in the body of the ABN. The beneficiary or
representative must select only 1 of the 3 checkboxes. Under no circumstances
can the notifier decide for the beneficiary or representative which of the 3
checkboxes to select. If the beneficiary cannot or will not make a choice, the
notice should be annotated.
If a beneficiary chooses to receive some, but not all of the items or services that
are subject of the notice, the items and services in Blank (D) that they do not wish
to receive may be crossed out, if this can be done in a way that also clearly strikes
the reason(s) and cost information in Blanks (E) and (F) that correspond to that
care. If this cannot be done clearly, a new ABN must be prepared.

Other Insurance
Blank (H) Other Insurance:
Completion of this blank is optional. Beneficiaries or their representatives may
write down any insurers or payers, other than Medicare, that may provide
payment for the care that is the subject of the notice.

Signature Box
Blank (I) Signature:
The beneficiary or representative must sign the notice, with his or her own name,
to indicate that he or she has received the notice and understands its contents.
Blank (J) Date:
The beneficiary or representative must write the date he or she signed the ABN.

-

(A) SupplierIProvider:
( B) Heneticiary Name:

(C) Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare does not pay for things listed below, you may have to pay.
We think Medicare will not pay for the "Item(s)/Service(s)" listed below because of certain rules for coveragc
described under "Reason". You still can receive this care, since you or your health care provider may have goo(
reason to think you need it, but it is likely you or other insurance will have to pay. We have estimated about hov
much you may have to pay under "Estimated Cost" to help you decide whether or not to receive the care listed.

(DlItem(s)/Seryice(s):
.--..-............. -....

...............

-Il.Y--.."._i-li

-..---. (ElIt-*:
I^- I

h4

--^.---%.--$-...r-L-rr

;P. ,

.

*~-rr----

. . . . - _(F)Estimated Coerts
_---&----"---

Medicare wants us to be sure you make an informed choice. Read this whole notice, which explains our
opinion that Medicare won't pay. This is not an official Medicare decision. Ask us for more ex lanation
if you need it. For uestions on this notice or on Medicare billing, you can also call
(1-800-633-42271;fiF~:1-877-46-2048).

~-SOO-MEDIEARE

You need to make a choice about receiving the care listed above. You must choose onlv one of the three
options below. We cannot choose for you.
We must bill Medicare when you ask us to. We may help ou with billing other insurance if you choose
Option 2 or 3 below, though Medicare cannot require us to o this.

dY

7

a 1. Do
not provide me with anything listed above. With no care provided, there is no billing.
I understand that I cannot appeal to Medicare when choosing this option.
a 2. Provide
me with what is listed above. I do not want Medicare billed. I agree to be responsible
for payment. I understand that I cannot appeal to Medicare when choosing this option.
a 3. payment.
Provide me with what is listed above. I want you to bill Medicare for an official decision on
You can ask for payment now that will be refunded if Medicare pays. I understand
that if Medicare does not pay, I can appeal that decision.

(H) Other insurance to consider for billing:
Your signature below means that you have received this notice and understand it. You will also get a copy.

(I) Signature:

(J) Date:

PIUVAY NOTICE: According to the Papwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OM
control number. The val~dOMB control number for t h ~ sinformation collection is 0938-0566. The time required to complete this information collection is estimated
average 1 0hoursX7 minutes) pcr response, including the time to review instnrctions, search existing data resources, gather the data needed, and complete and review 11
information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form. please write to: CMS, 7500 Securi
Boulevard. Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore, Maryland 21254-1850.

OMB Approval No. 0938-0566

Form No. CMS-R-131

(June 2007)

Patient's Name:

Medicare # (HICN):

ADVANCE
BENEFICIARY
NOTICE
(ABN)
NOTE: You need to make a choice about receiving these health care items or services.
We expect that Medicare will not pay for the item(s) or service(s) that are described below.
Medicare does not ay for all of your health care costs. Medicare only pays for covered ~tems
and services when edicare rules are met. The fact that Medicare may not pay for a particular
item or service does not mean that you should not receive it. There may be a good reason your
doctor recommended it. Right now, in your case, Medicare probably will not pay for
Items or Serv~ces:

Rl

-

Because:

The purpose of this form is to
want to receive these items
Before you make a decision
Ask us to explain, if you don't
Ask us how much these items or services wil
in case you have to pay for them yourself or
I

(

PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.

Option 1. YES.

I want to receive these items or services.
I understand that Medicare will not
or services. Please submit my
items or services and that I

Option 2. NO. I have decided not to receive these items or services.
I will not receive these items or services. I understand that you will not be able to submit a
claim to Medicare and that I will not be able to appeal your opinion that Medicare won't pay.
Date

Signature of patient or person acting on patient's behalf

NOTE: Your health information will be kept confidential. Any information that we collect about you on this
form will be ke t confidential in our offices. If a claim is submittedto Medicare, your health informationon this form
may be share with Medicare. Your health informationwhich Medicare sees w~llbe kept confidential by Medicare.

B

OMB Approval No. 0938-0566

Form No. CMS-R-131-G

(June 2002)

Patient's Name:

Medicare # (HICN):
-

ADVANCE
BENEFICIARY
NOTICE(ABN)
NOTE: You need to make a choice about receiving these laboratory tests.
We expect that Medicare will not pay for the laboratory test(s) that are described below.
Medicare does not ay for all of your health care costs. Medicare only pays for covered items
and services when edicare rules are met. The fact that Medicare may not pay for a particular
item or service does not mean that you should not receive it. There may be a good reason your
doctor recommended it. Right now, in your case, Medicare probably will not pay for the
laboratory test(s) indicated below for the following reasons:

R,

The purpose of this form is to he1 you make an informed choice about whether or not you
want to receive these laboratory ests, knowing that you mi ht have to pa for them yourself.
Before you make a decision about your options, you shoul read this en ire notice carefully.
Ask us to explain, if you don't understand why Medicare robabl won't pay.
Ask us how much these laboratory tests will cost you (Es imated ost: $
in case you have to pay for them yourself or through other insurance.

P

?'

I? 8

?

1 9

PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.

Option 1

I understand that
tests and that I

Option 2. NO. I have decided not to receive these laborato
I will not receive these laboratory tests. I understand that you will not be ab etests.
to submit a
claim to Medicare and that I will not be able to appeal your o inion that Medicare won't pay.
I will notify my doctor who ordered these laboratory tests tha I did not receive them.

P

Date

7

Signature of patient or person acting on patient's behalf

NOTE:, Your health infoamationwill be kept confidential. Any information that we gllect about you on this
form will be ke t confident~alin our offices. If a claim is submitted to Medicare,your health informat~onon th~sform
may be sharefwith Med~care.Your health information which Medicare sees w~llbe kept confident~alby Medicare.
OMB Approval No. 0938-0566 Form No. CMS-R-131-L (June 2002)

NOTICEOF EXCLUSIONS
FROM MEDICARE
BENEFITS (NEMB)
There are items and services for which Medicare will not pay.
Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits.
Some items and services are not Medicare benefits and Medicare will not pay for them.
When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it,
personally or through any other insurance that you may have.
The purpose of this notice is to help you make an informed choice about whether or not
ou want to receive these items or services, knowing that yo11will have to pay for them yourself.
hefore you make a decision, you should read t h ~ sentire notice carefully.
Ask us to explain, if you don't understand wh Medicare won't pay.
Ask us how much these items or services wil cost you (Estimated Cost: $
1.

Y

M e d i c a r e will not pay for:
5

a 1.
2.

B e c a u s e it d o e s not m e e t the definition of a n y Medicare benefit.
B e c a u s e of t h e following e x c l u s i o n * from Medicare benefits:

o Routine physicals and most tests for screening.
Personal comfort items.
o Routine eye care, eyeglasses and examinations.
Most shots (vaccinations).
Cosmetic surgery.
Hearing aids and hearing examinations.
o
Dental
care and dentures (in most cases).
Most outpatient prescription drugs.
o Orthopedic shoes and foot supports (orthotics).
Routine foot care and flat foot care.
Services by immediate relatives.
Health care received outside of the USA.
Services required as a result of war.
Services under a physician's private contract.
Services paid for by a governmental entity that is not Medicare.
Services for which the patient has no legal obligation to pay.
o Home health services furnished under a plan of care, if the agency does not submit the claim.
ltems and services excluded under the Assisted Suicide Funding RestrictionAct of 1997.
ltems or services fumished in a competitive acquisition area by any entity that does not have a contract
with the Department of Health and Human Services (except in a case of urgent need).
Physicians' services performed by a physician assistant, midwife, psychologist, or nurse anesthetist,
when furnished to an inpatient, unless they are fumished under arrangements by the hospital.
ltems and services furnished to an individual who is a resident of a skilled nursing facility (a SNF)
or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF.
Services of an assistant at surgery without prior approval from the peer review organization.
Outpatient occupational and physical therapy services furnished incident to a physician's services.

* This is only a general summary of exclusions from Medicare benefits. It is not a legal document.
The official Medicare program provisions are contained in relevant laws, regulations, and ~ l i n g s .

Form No. CMS-20007 (January 2003)