ABNinstructionrationaleforchange

Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131

OMB Approval No. 0938-0566

Request for Minor Revision to Notice Instructions

We would like to make a minor revision to the instructions that accompany the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 and approved by the Office of Management and Budget (OMB) in 2011 under OMB approval number 0938-0566.

Our existing published instructions for completion of the ABN state that the notifier (the supplier or provider) completes blank (D) on the notice, and the beneficiary or representative completes blank (G). However, within the area that is blank (G), there are 3 blanks labeled (D). While most notifiers understand that it is their responsibility to complete the blanks labeled (D) that are within blank (G), a few notifiers have contacted us for clarification. We propose a minor change to the language on page 2 of the instructions under “Sections and Blanks” to clarify this issue. This added language is below in red italics.

Sections and Blanks:

There are 10 blanks for completion in this notice, labeled from (A) through (J), with accompanying instructions for each blank below. We recommend that the labels for the blanks be removed before use. Blanks (A)-(F) and blank (H) may be completed prior to delivering the notice, as appropriate. 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. (Note that 10 point font can be used in blanks when detailed information must be given and is otherwise difficult to fit in the allowed space.) The notifier must also insert the blank (D) header information into the blanks labeled (D) within the Option Box, Blank (G). The check boxes in the Option Box, Blank (G), must be completed by the beneficiary or his/her representative. Blank (I) should be a cursive signature, with printed annotation if needed in order to be understood.