Crosswalk

Crosswalk Document for Changes to CMS-R-131
Advance Beneficiary Notice of Noncoverage
Submitted for Collection October 2015

Summary of Changes to CMS-R-131:
The Advance of Beneficiary Notice of Noncoverage (ABN) is delivered to beneficiaries
in certain instances by Part B paid physicians, providers (including institutional providers
like outpatient hospitals), practitioners (such as chiropractors), and suppliers, as well as
hospice providers and Religious Non-medical Health Care Institutions paid under Part A.
Home health agencies providing items and services under Part A or Part B also use the
ABN since 2013. Other Medicare institutional providers paid under Part A use other
approved notices for this purpose. Delivery of this liability notice is required prior to
beneficiaries receiving usually covered items or services that might not be paid for by
Medicare in a specific instance. The ABN was last approved under PRA in 2013 and nonsubstantive changes to the ABN form instructions addressing ABN issuance for nonassigned claims were approved on June 30, 2015. With this submission, there is one
minimal, non-substantive change to comply with Section 504 of the Rehabilitation Act of
1973 (Section 504), which requires Federal Agencies to be non-discriminatory and
provide this publication in an alternative format if needed. No substantive changes have
been made to the existing form.
The following non-substantive changes have been made to the form:
• The form has been revised to include language informing beneficiaries of CMS
nondiscrimination practices and their right to request this publication in an
alternative format if needed.
The following non-substantive changes have been made to the form instructions:
• Minor language and grammar edits were made throughout the form instructions to
improve comprehension and decrease the probability of provider/supplier error in
completing the ABN.
• Incorrect reference to §50.14.3 in the form instructions was changed to the correct
reference §50.7.1(b).
The ABN is an existing collection and is in use. It is our expectation that the nonsubstantive changes to the form and form instructions will have little effect on burden for
all users. The Section 504 requirement was in effect with the prior notice, and including
standard CMS language to advise the beneficiary of nondiscrimination and availability of
alternate forms of this notice is not expected to change burden estimates associated with
the ABN. Minor edits to the form instruction were made to provide clarity and assist
providers/suppliers with proper ABN delivery, which should slightly ease the burden of
form completion, but is not expected to cause a dramatic change in burden estimates for
the ABN.