The Advanced Beneficiary Notice of Noncoverage (ABN) is a standardized document designed to protect Medicare beneficiaries from unexpected medical bills. This notice informs individuals that Medicare may not pay for a specific service or item, giving the beneficiary a choice to either receive the service and accept financial responsibility or refuse it. While the ABN is central to the Original Medicare program, it is generally not used for patients enrolled in a Medicare Advantage (MA) plan. MA plans, also known as Medicare Part C, are offered by private companies providing Part A and Part B benefits. Because these private plans operate under different regulations, they utilize separate, plan-specific notices when denying coverage.
The Purpose and Scope of the ABN
The ABN is specifically intended for beneficiaries enrolled in Original Medicare, the traditional fee-for-service program encompassing Part A (Hospital Insurance) and Part B (Medical Insurance). Healthcare providers, physicians, and suppliers must issue this notice when they believe a service or item that Medicare usually covers will likely be denied. The most common reason for denial is that the service is deemed not “medically reasonable or necessary” according to Medicare standards.
The form transfers potential financial liability from Medicare and the provider to the beneficiary. By signing the ABN, the patient acknowledges that Medicare may not pay and agrees to be personally responsible for the cost of the service if Medicare ultimately issues a denial. Providers must deliver the ABN in advance so the beneficiary can make an informed decision before receiving the care.
The ABN is strictly governed by Medicare Part A and B rules, and its use is mandatory only in certain situations under Original Medicare. It is not used for items or services that are never covered by Medicare, such as hearing aids or cosmetic surgery. For beneficiaries enrolled in a private Medicare Advantage plan, the rules for non-coverage notification are entirely different.
The Required Notification Process for Medicare Advantage
Medicare Advantage plans operate under Medicare Part C and must follow a separate set of rules for coverage determinations and denial notices. These private plans are responsible for making an initial coverage decision, known as an Organization Determination, for nearly all services. When an MA plan denies a request for coverage or payment, or decides to reduce or stop a previously authorized service, the plan itself must issue a specific notification.
The primary form used for most service and payment denials is the Integrated Denial Notice (IDN). This notice informs the enrollee of the plan’s decision and provides details about their appeal rights. Since the plan, not the provider, is making the coverage decision, the provider-issued ABN is not the correct document to use.
For services ending in certain institutional settings, a different form is required, known as the Notice of Medicare Non-coverage (NOMNC). This form is delivered to enrollees receiving covered skilled services, such as those in a Skilled Nursing Facility (SNF) or Home Health Agency (HHA) services, when the services are about to be terminated. The NOMNC must be delivered at least two calendar days before the covered services end to allow time for the enrollee to request an expedited appeal.
Understanding Your Rights: Appeals in Medicare Advantage vs. Original Medicare
In Original Medicare, a beneficiary who signs an ABN and receives the service receives a denial on their Medicare Summary Notice (MSN). The appeal process proceeds through five levels, starting with reconsideration by the Medicare Administrative Contractor (MAC). Further appeals include review by a Qualified Independent Contractor (QIC), an Administrative Law Judge (ALJ) hearing, the Medicare Appeals Council, and judicial review in federal district court.
In Medicare Advantage, the appeal process begins with the Organization Determination issued by the plan. If the enrollee disagrees with the denial outlined in the IDN or NOMNC, they can request a Plan Redetermination, which is the first level of appeal handled internally by the MA plan. If the plan upholds its denial, the case is automatically forwarded to the second level of appeal, reviewed by an Independent Review Entity (IRE), an external organization contracted by CMS.
The MA appeal process includes the availability of expedited or “fast-track” appeals, particularly when a service, such as a hospital stay or home health care, is ending. In these time-sensitive situations, the enrollee may request a review from the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Deadlines for filing appeals are stricter in MA plans, generally requiring a request within 60 days of the denial notice, compared to longer timeframes in Original Medicare.