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Medicare non covered reasons and ABN notice
ROUTINE NOTICE PROHIBITION
Providers are prohibited from issuing ABNs on a routine basis (i.e., where there is no reasonable expectation of non-coverage). Providers will not violate the routine notice prohibition solely on the basis of the number of ABNs issued as long as there is a reasonable basis for issuing an ABN.
TO WHOM SHOULD AN ABN BE GIVEN?
The Medicare beneficiary.
The Medicare beneficiary’s representative under applicable state or other law. A representative is an individual who may make health care and financial decisions on a beneficiary’s behalf (e.g., legal guardian or someone appointed according to a properly executed “durable medical power of attorney”).
REASONS FOR NON-COVERAGE
Services denied by the Medicare program as not medically necessary or reasonable fall into these general categories:
Experimental and investigational.
Not safe and effective.
Limited coverage based on certain criteria.
Number of services exceeds the norm and no medical necessity demonstrated for the extra number of services.
Labels: Medicare basic concept
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