CMS debuted an updated ABN for use this summer but delayed implementation due to the pandemic. The new form addresses dual eligibility for beneficiaries and provides new guidance. CMS now offers additional guidelines for dual-eligible beneficiaries (covered by both Medicare and Medicaid).
- *Special guidance for people who are dually enrolled in both Medicare and Medicaid, also known as dually eligible individuals (has a Qualified Medicare Beneficiary (QMB) Program and/or Medicaid coverage) ONLY:
- Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.
Strike through Option Box 1 as provided below:
- □ OPTION 1. I want the (D) 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.
CMS has made these edits to clarify that providers cannot bill dual-eligible beneficiaries when the ABN is furnished. The facility should consider the following situation. Suppose Medicare denies a claim where an ABN was needed to transfer financial liability to the beneficiary. In that case, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.