Advance Beneficiary Notice of Non-coverage Form

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Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for PT Services below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the PT Services below.

D. Physical Therapy Services	E. Reason Medicare May Not Pay	F. Estimated Cost
PT Services	• Yearly CAP has been reached • Services exceed $2480, so will be denied • No Medicare allowed Rx on file • The diagnosis/treatment techniques used are not covered by Medicare. • You have instructed us to bill another insurance company for these services. • Therapist believes this treatment is not medically necessary	Treatment, evaluation, reevaluation: $150 per session

What You Need to Do Now

Read this notice to make an informed decision about your care.
Ask any questions you may have before signing.
Choose one of the options below.

Note: If you choose Option 1 or 2, we may help you to use any other insurance you have, but Medicare cannot require us to do this.

G. Select the opiton you desire (Required):

OPTION 1: I want the item, test, service or care listed above, and I want Medicare to be billed for an official decision on payment, which I’ll get on a Medicare Summary Notice (MSN). You can ask to be paid now. I understand that if Medicare doesn’t pay, I’m responsible to pay, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you’ll refund any payments I made to you, minus co-pays or deductibles.

OPTION 2: I want the item, test, service or care listed above, but don’t bill Medicare. You can ask to be paid now and I’m responsible to pay. I understand that I can’t appeal, since Medicare isn’t billed.

OPTION 3: I don’t want the item, test, service or care listed above. I understand I’m not responsible for payment and I can’t appeal to see if Medicare would pay.

H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (TTY: 1-877-486-2048). Signing below means you have received and understand this notice. You may request a copy.

You have the right to get Medicare information in an accessible format—large print, Braille, or audio—and to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. This information collection is for providers, suppliers, Hospice and Religious Non-medical HealthCare Institutes and Home Health Agencies to notify original Medicare beneficiaries of their potential financial liability under specific conditions. The time required to complete this information collection is estimated to average less than 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory under Section 1879 of the Social Security Act, 42 CFR 411.404(b) and (c) and 411.408(d)(2) and (f). If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp.03/31/2029) Form Approved OMB No. 0938-0566

You will receive a copy of this document via email. For your information, here is the document format you will receive filled out, click here.

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