Advanced Beneficiary Notice of Coverage (ABN)

Advanced Beneficiary Notice of Coverage (ABN)

NOTE: If Medicare doesn't pay for D. Routine Foot Care 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 D. Routine Foot Care below.
Name *

First Name Last Name

D. Rountine Foot Care

E. Reason Medicare May Not Pay

F. Estimated Cost

Thick Nails

11721

11720

Normal Nails

11719

Calluses

11055

11056

11057

Patient has not met DEDUCTIBLE

Minimum Deductile is $200 for 2020

11721- $47.21

11720- $34.14

11719-$14.93

11055-$57.32

11056- $68.68

11057-$76.48

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 D. listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance
that you might have, but Medicare cannot require us to do this.
Options:
Please select an option: *

Option 1: I want the D. Routine Foot Care listed above. You may ask to be paid now, but Ialso 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 D. Routine Foot Care listed above, but do not bill Medicare. You mayask 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 D. Routine Foot Care listed above. I understand with this choice Iam not responsible for payment, and I cannot 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 (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that ou have received and understand this notice. You also receive a copy.
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Advanced Beneficiary Notice of Coverage (ABN)

Options: