Advance Beneficiary Notice Of Noncoverage (Abn), Self Pay Notice Forms
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4Advance Beneficiary Notice of Noncoverage (ABN)
Medicare
Use Medicare approved ABN (CMS-R-131).
Complete all sections A-J.
A) Enter CoxHealth Home Support, 2240 W. Sunset St.,100. Springfield, MO 65807.
B) Patient’s name should be entered the same as it is on their Medicare card.
C) No Social Security numbers or Medicare numbers on the ABN.
D) List specific items.
No abbreviations or general descriptions such as “supplies”.
E) Detailed reason why the equipment is not medically necessary.
Use beneficiary-friendly language.
No abbreviations.
Stay away from phrase “may not”.
F) Enter cost.
G) Patient must choose an option.
H) Use for additional information if needed.
Patient’s signature or representative’s signature.
I)
If representative signs then “representative” or relationship should be after signature.
J) Date of signature.
There should always be two copies of the ABN: one for the patient and one for us.
ABNs are valid for 1 year. If the rental is longer than 1 year then a new ABN needs to be signed every year.
(e.g. Oxygen)
BCBS/Anthem
Use CoxHealth Home Support approved Self Pay Notice.
Complete all sections.
Follow Medicare instructions for the Item and Reason sections.
UHC
Use CoxHealth Home Support approved Self Pay Notice.
Complete all sections.
Follow Medicare instructions for the Item and Reason sections.
CoxHealth
Use CoxHealth Home Support approved Self Pay Notice.
Complete all sections.
Follow Medicare instructions for the Item and Reason sections.
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Rev 10/04/2011
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