ABN Advance Beneficiary Notice

Advance Beneficiary Notice of Noncoverage (ABN)
The attached Advance Beneficiary Notice of Noncoverage (“ABN”) is given to certain Medicare beneficiaries (“Recipients”) to advise Recipients that Medicare may not provide coverage for the treatment specified on the ABN.

The ABN is a written notice that provides you with an opportunity to accept or refuse the items or services listed on the ABN, and protects you from unexpected financial liability in cases where Medicare denies payment. Pursuant to our Patient Financial Policies, you are required to pay in full for any services for which Medicare denies payment. You have the right to appeal Medicare’s decision in the event Medicare denies payment.

Please review the attached ABN and complete the form as follows:
Choose the service you are seeing IGIC specialist for: *
IF YOU ELECT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED
- Check “OPTION 1” on the attached form;
- Sign and date the attached form;
- The practice will submit the claim for the listed services to Medicare. Note that you may be billed while Medicare is making its decision;
- If Medicare pays the claim, you will be refunded any payments that are due to you;
- If Medicare denies the claim, you will be personally responsible for full payment of the services rendered;
- You will have the right to appeal Medicare’s decision.
IF YOU ELECT NOT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED
- You must check “OPTION 2” on the attached form;
- Sign and date the attached form;
- The practice will not submit the claim to Medicare.
ALTHOUGH MEDICARE MAY NOT COVER THE LISTED ITEMS OR SERVICES, THERE MAY BE A GOOD REASON FOR YOUR PHYSICIAN RECOMMENDING THE LISTED COURSE OF CARE. PLEASE NOTIFY YOUR DOCTOR OF ANY REFUSAL OF CARE.
NOTE: If Medicare doesn’t pay for your (D. service), 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.
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 D (service 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 : you must chose one, we may not chose for you.

OPTION 1. I want D (service 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 D (service 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 D (service listed above). I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
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 you have received and understand this notice.
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Advance Beneficiary Notice of Noncoverage (ABN)

IF YOU ELECT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED

IF YOU ELECT NOT TO RECEIVE THE ITEMS OR SERVICES THAT MAY NOT BE COVERED

WHAT YOU NEED TO DO NOW:

Additional Information: