Palmetto GBA

LICENSE FOR USE OF "Physicians' CURRENT PROCEDURAL TERMINOLOGY",
FOURTH EDITION ("CPT")

You, your employees and agents are authorized to use CPT internally within your organization for the sole use by yourself, employees and agents. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. You should contact Paul A. Markowski at the American Medical Association, CPT Intellectual Property Services, American Medical Association, 515 N. State Street, Chicago, Illinois 60610 or at telephone number 312-464-5943 or at facsimile number 312-464-5762, should you wish to make additional uses of CPT.

Applicable FARS/DFARS Restrictions Apply to Government Use. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)(June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14(June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14(June 1987) and FAR 52.227-19(June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed of implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is the Health Care Financing Administration and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "ACCEPT".
FOURTH EDITION ("CPT")

Disclaimer of Warranties and Liabilities.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "ACCEPT".

Close Window [x]

Railroad Beneficiaries Railroad Beneficiaries
Railroad Providers Railroad Providers

Palmetto GBA Corporate Palmetto GBA Medicare

Articles

Fraud & Abuse

Interactive Voice Response Information

Preventive Services

Resources

#StayConnected

Auxilary Aids & Services

For information about the availability of beneficiary auxiliary aids and services, please call our Beneficiary Contact Center at 800-833-4455.

Advance Beneficiary Notice of Noncoverage: What Is An ABN and Why You May Be Asked To Sign One

You may have noticed an additional form in the paperwork you fill out when you go to the doctor’s office these days. In some circumstances, you may be asked to sign an Advanced Beneficiary Notice of Noncoverage or ABN, which is used by providers to alert you that a service is not expected to be covered by Medicare. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

Though not all services are covered by Medicare, an ABN cannot be used in situations where you need immediate medical attention.

The following are examples of when an ABN can be used for non-covered services:

Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
Services paid for by a government entity other than Medicare
Personal comfort items
Some screening tests
Routine eye care
Dental care
Routine foot care

The Centers for Medicare and Medicaid (CMS) provides doctors and other health care professionals with a standardized form to use; however, it does allow them to use their own form as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:

Give the name or description of the service they are providing
Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'
Give you the estimated cost of the service or procedure
Provide you with three options, worded in the following ways:
- Option 1. 'I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.'
- Option 2. 'I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.'
- Option 3. 'I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.'

The ABN will also have a place for additional information, such as a dated witness signature.

There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.

Some points to remember:

Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.
Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.
If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurances may cover services that Railroad Medicare does not.

If you have questions regarding Advanced Beneficiary Notices of Noncoverage, please call the Railroad Medicare Beneficiary Contact Center at (800) 833-4455. Representatives are available Monday through Friday from 8:30 a.m. to 7 p.m. ET.

last updated on 09/13/2011

ver 1.0.26