CMS-R-131 Comment #43

R. DEAN HARMAN, D.C.

HARMAN CHIROPRACTIC CENTER
1407 South "B" Street
San Mateo, California 94402-2433

Chiropractic Care for the Family

(650)571-1122
Fax: (650)571-1265

312 1107
CMS
7500 Security Blvd.
Attn: PRA Reports Clearance Officer
Mail Stop C4-26-05
Baltimore MD 2 1244- 1 850

I have just downloaded the proposed new A3N and am absoiucely horrified by ~iieerrors III ii.
See the copy attached and corrections below.
1) The quote mark should appear after the period. Should be .....described under "Reason."
2) "You may receive ....."

3) 'about' is superfluous when used with 'estimated.' Should be "We have estimated how much
you may ... "
4) Should be " .... opinion that Medicare will not pay."

5) Should be " ... though Medicare does not require us to do this."
6) The 3rdsentence under #3 makes no sense. "You can ask for payment now that will be
refunded if Medicare pays." Does this sentence refer to the doctor or to the patient? If it pertains
to the patient why would the patient ask for payment; and payment from whom?

7) Privacy Notice at bottom-'Privacy'

,

is misspelled.

8) "things" is not very expressive, PLUS it may not be a thing but a service. Therefore suggest
the sentence read: "NOTE: There are limits to what Medicare will pay for; you may have to pay."
9) I questions that there is such a word as noncoverage. I believe it should bc Non-covcrage or
Non-Coverage but that should be determined by an appropriate editor.

10) Replace the word "get" with "receive" a copy.

K. Dean IIarman, DC

(C) Identification Number:

(B) Beneficiary Name:

Advance Beneficiary

notice^
Non%verase
w

(ABN)

NOTE: If Medicare does not pay for thp@listed below, you may have to pay.

5

pay for the "Item(s)/Service(s)" listed below because of certain rules for coverage
h
e think Medicare will
ceive this care, since you or your health care provider may have
1 can
w d e s c r i b e d under "Reaso
reason to think you nee 1 but it IS 1 e y you or other insurance will have to pay. We have estimatedho
much you may have to pay under "Estimated Cost" to help you decide whether or not to receive the care listed.

Po-

(D) Item(s)lSewice(s):

.... , .... .. ,... ....,. .,... .

.,..

.......... .. .....................,., ,..,..

..,..... ,,... ...

_

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

',.., ................

(E) Reason:

..........................................................
4 ,,,.,,.,.,..
,,,.,,,,,...
,,,,,,....,,,,,,..
;

'....

(F)Estimated Cost:
:

e you make an informed choice. Read this whole notice, which explains our
ay. This is not an official Medicare decision. Ask us for more explanation
this notice or on Medicare billing, you can also call 1-800-MEDICARE
You need to make a choice about receiving the care listed above. You must choose only one of the three
options below. We cannot choose for you. p

ou with billing other insurance if you choose

We must bill Medicare
Option 2 or 3 below, though
I

I

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.

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 a p p e d to Medicare when choosing t h i s option.
Provide me with what is listed above. I want you to bill Medicare for a n official decision on
ayment. You can ask for payment now that will be refunded if Medicare pays. I understand 7,
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 als
/ /
-/ ( I ) Signature:
(J) Date:
?-

I

=;\I;'&

a

1

'YOTICE: According to the Paperwork Reduct~onAct of 1995, no persons are required to resdond to a collection of information unless it displays a valid O d B

b u n l r c h l number The valid OMB conlrol nurnber for this information collecr~onis 0938-0566. The time required to complete this information collection

IS

estimated to

itberage (0hoursK7 m~nutes) per response, including the time to review instruct~ons,search exsting data resources, gather the data needed, and complete and review the
~nlbrrnatloncollect~on I f you have comments concerning the accuracy o f the time esrimale or suggestions for improving this form, please write to. CMS, 7500 Security
I3ouIsv'trd. -111nPRA Reports Clearance Officer. Mail Stop C4-26-05, Balt~more.Maryland 2 1244-1850.

O M B Approval No. 0938-0566

Form No. CMS-R-131

(June 2007)