Advanced Beneficiary Notice of Non-Coverage (ABN)

Advance Beneficiary Notice of Non-Coverage (ABN)

NOTE: If Medicare doesn't pay for the ambulance services 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 ambulance services listed below.
Patient Name*

First NameLast Name
Medicare/Medicaid Identification Number
Services:

Ambulance Transport and Mileage

Reason Medicare May Not Pay:

___ Medicare does not pay for transportation from residence or a SNF for services tha could more economically be performed at the residence or SNF.

___ Medicare does not pay for ambulance service that is not medically necessary.

_X_ Medicare does not pay for transports to a doctor's office or other non-covered destinations.

___ Medicare does not pay for transports for the convenience of a patient, family or physician.

___ Medicare does not pay for mileage beyond the closest appropriate facility.

___ Medicare does not pay for a higher level of service (Advanced Life Support) when a lower level of service (Basic Life Support) would suffice.

Estimated Cost:

$850.00 Ambulance Base Rate

Plus

$22.00 per loaded mile
WHAT DO YOU NEED TO DO NOW:
1. Read this notice, so you can make an informed decision about your care.
2. Ask us any questions that you may have after you finish reading.
3. Choose an option below about whether to receive the ambulance services listed above.Note: If you choose Option 1 or 2, we may help you to use any other insuance that you might have, but Medicare cannot require us to do this.
Options: Check only one box. We cannot choose a box for you.*

Option 1: I want the ambulance services 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 ambulance services 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 ambulance services 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).

Signing below means that you have received and understand this notice. You also receive a copy.
Signature*

Clear
Date*

MonthDayYear
Date
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

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Advance Beneficiary Notice of Non-Coverage (ABN)