Anthem Advance Beneficiary Notice Of Noncoverage
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1
A
A
B
N
(ABN)
N
NTHEM
DVANCE
ENEFICIARY
OTICE
OF
ONCOVERAGE
Patient Name: _________________________________________ ACIS ID/CPU: __________________
Anthem Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare or your insurance carrier doesn’t pay for positive airway pressure (“PAP”) device and related
equipment (to be used on an ongoing basis), as well as related supplies (to be ordered by you as needed), you may
have to pay if you fail to demonstrate continued usage of your PAP device.
Your insurance carrier does not pay for everything, even some care that you or your health care provider
have good reason to think you need. For the reasons listed below, we expect your health insurer may not
pay for the equipment/supplies listed below.
List of Equipment
Reason Carrier May Not Pay:
Estimated Cost
Positive Airway Pressure (“PAP”) device
If you fail to demonstrate and
See attached Sales,
and related equipment (to be used on an
document continued usage of your
Service, and Rental
ongoing basis), as well as related
PAP device as required by the terms
Agreement for detailed
supplies (to be ordered by you as
of your health coverage.
charges
needed)
WHAT YOU NEED TO DO NOW:
•
Read this notice, so you can make an informed decision about your care.
•
Ask us any questions that you may have after you finish reading.
•
Choose an option below about whether to receive the equipment listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you
.
might have, but your health insurer cannot require us to do this
O
:
Check only one box. We cannot choose a box for you.
PTIONS
☐ OPTION 1. I want the Positive Airway Pressure (“PAP”) device and related equipment (to be used on an
ongoing basis), as well as related supplies (to be ordered by you as needed). You may ask to be paid now, but
I also want my insurance carrier billed for an official decision on payment, which is sent to me on a explanation
of payment form. I understand that if my health insurer doesn’t pay, I am responsible for payment, but I can
appeal to insurer by following the directions of my insurance carrier. If my insurance carrier does pay you, you
will refund any payments I made to you, less co-pays or deductibles.
☐ OPTION 2. I want the Positive Airway Pressure (“PAP”) device and related equipment (to be used on an
ongoing basis), as well as related supplies (to be ordered by you as needed), but do not bill my insurance
carrier. You may ask to be paid now as I am responsible for payment. I cannot appeal if my insurance carrier is
not billed.
☐ OPTION 3. I don’t want the Positive Airway Pressure (“PAP”) device and related equipment (to be used on
an ongoing basis), as well as related supplies (to be ordered by you as needed). I understand with this choice I
am not responsible for payment, and I cannot appeal to see if my insurance carrier would pay.
Additional Information:
This notice gives our opinion, not an official health carrier decision. If you have other questions on
this notice contact your insurance carrier.
By signing below, means that you have received and understand this notice. You also receive a copy.
Patient Signature:
Date:
RMSD-00188
11/30/12
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