CMS-R-131 Comment #3 thru #5

3500 Arendell Street - P.O. Drawer 1619 - Morehead City, NC 28557-161 9
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www.ccph.o~- Telephone (252) 808-6000, FAX (252) 808-6985

carteret
General
Hospital

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Kenneth C. Wagner, Jr.
Chairman
Frederick A. Odell, 111. FACHE

June 8,2007
CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Blvd.
Baltimore, Maryland 21244-1850
Dear Sir or Madam:
This letter is in response to information we received on behalf of CMS/CMS Provider
Resource requesting additional Public Comment on the Revised Advance Beneficiary Notice
(ABN). Please consider the following during this comment period:

1. Under (G) Options number 3, where it states " I understand that if Melcare does
not pay, I can appeal that decision". Can an additional statement be added, but
ultimately I am res~onsiblefor ~avment.
2. Can a total cost field be added to the ABN Form?

3. If Blank (H) Other insurance to consider for billing is optional, is it required to be
on the ABN Form?
?'hank you for your consideration.

Sincerely,

Lynn S. Godette,
Compliance Administrator

Making A Difference In Your Life

Dr. Thomas G. Bruno
CHIROPRACTOR

142 GARDNER ROAD
P.O. BOX 42
TROUT CREEK, MI 49967
(906) 052-3371

CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development - C
Attention: Bonnie L. Harkless
Room C4-26-05,
7500 Security Blvd.
l3altimore, Maryland 2 1244- 1850

Dear Ms Harkless,

May I respectfully suggest in (G) Option Box, a modified wording for Option 1 (shown below in blue) for the
fbllowing reason:
The original wording instructs the provider to r e b d any payment made by the patient regardless
whether a Medicare payment is sent to the provider or directly to the patient.
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Example: 'a non-participating provider (who does not accept assignment) collects payment from the
patient at time of service and bills Medicare on behalf of the patient with instructions for Medicare to
pay benefits directly to the patient. If the patient subsequently receives benefit payment fiom
Medicare, there is no reason for the provider to rehnd the patient.

OPTION 1. 1 want the items or services e

~ t above.
d
You may collect money from me
now, but I also I want Medicare billed for an official decision on payment, which is sent to me on
a Medicare Summary Notice (MSN). Iunderstand that if Medicare doesn't pay, I am
responsible for payment, but Ican appeal to Medicare by following the directions on the MSN.
If Medicare pays a u , you will refund any payments I made to you, less co-pays or deductibles.

Thank you for your consideration on this matter.
Sincerely,

Thomas G. Bruno. D.C.

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COUNTY OF SUFFOLK

STEVE LEVY
SUFFOLK COUNTY EXECUTIVE

DEPARTMENT OF HEALTH SERVICES

HUMAYUN J. CHAUDHRY, D.O., M.S.
Commissioner

June 14,2007
CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development - C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Blvd.
Baltimore, Maryland 21244- 1850
Ref: CMS-R-131 ABN
Dear Ms. Harkless:
I would like to take this opportunity to make the following comments about the newly drafted Advance
Beneficiary Notice of Noncoverage (ABN),of which comments are being accepted until June 24,2007:
1. We would like to see one ( 1 ) form with Laboratory and General combined, specifically Laboratory
and Services as for Physician Services.

2. The Spanish versions should come out simultaneously with the English versions.
3. The User-CustomizableSections on page 7 of the Part-l - Instructions for Carriers, Physicians and
Suppliers in Section E, number 3 should have a clearer description of what can be customized by
the physician in reference to the newest drafts.
4. We would recommend the Confidential Statement language be put back in as in the older forms.
5. We would like to know the date or timeframe of when the forms will be approved and ready for
use.
Thank you, and if you would like to contact me, I can be reached by email at
Shellie.Dworkin@suffolkcount~nv.aov
or by telephone
at 63 1 853-8084.
Sincerely,

+"
Shellie Dworkin, MPS,RHIA,CPHQ

Medical Records Administrator

Cc:
OMB Human Resources and Housing Branch
Attention Carolyn Lovett
New Executive Office Building, Room 10235
Washington, DC 20503
Fax# (202) 3956974

DIVISION OF PATIENT CARE SERVICES
225 Rabro Drive East, Hauppauge, NY 11788 (631) 853-3013 Fax (631) 853-3031