Transcript name of test - PGXL Laboratories

Leading with Compliance: The
Advanced Beneficiary Notice
(ABN) Form
Brad Esarey, Vice President of Sales
Agenda
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What is the ABN Form?
What does it do?
Who is it for?
Why do you need to fill out the form?
How do you fill out the form?
What is the ABN Form?
The Advanced Beneficiary
Notice (ABN) is documentation
that assures Medicare patients
have been fully informed of
their responsibility to pay for
tests ordered but not routinely
reimbursed by Medicare. It is
a legal requirement for people
enrolled in original, fee-forservice Medicare.
What does the ABN do?
The ABN enables the beneficiary to make an informed decision about
whether to order services and accept financial responsibility for those
services if Medicare does not pay.
The ABN serves as proof that the beneficiary knew prior to getting the
service that Medicare might not pay.
If you do not issue a valid ABN to the beneficiary when Medicare
requires, you cannot bill the beneficiary for the service and you may be
financially liable.
Who is the form for?
The ABN is for Medicare patients only.
The Advance Beneficiary Notice (ABN) is only administered to
MEDICARE beneficiaries.
It is a written notice that the Ordering Physician or healthcare provider
gives to a Medicare Beneficiary.
The ABN is required for
the following tests:
CYP2C9
VKORC1
CYP1A2
CYP3A4
CYP3A5
SULT4A1
SLC6A4 (Serotonin
Transporter)
SLCO1B1
OPRM1
Why do you need to fill out the form?
A properly executed ABN is required to allow PGXL Laboratories to bill
the patient.
The ABN must be signed before the sample is collected.
How to fill out the form
1. Use the most current version of The Advanced Beneficiary Notice of
Noncoverage (ABN), Form CMS-R-131(03/11)
2. Complete the ABN in pen by providing the required information in
the spaces provided on the form.
a. Patient’s full name as it appears on his or her Medicare Card
b. Medicare Number (HICN number)
c. Complete the reason you expect Medicare to deny the claim by writing the
test name in the appropriate column
i. Medical Necessity
ii. Frequency Limitations
iii. Experimental or research test
d. Estimate the laboratory cost using the PGXL LIST fee schedule
e. Allow the patient to select one of the following options
OPTION 1: I want the D. (name of test) 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 D. (name of test) 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. (name of test) listed
above. I understand with this choice I am not
responsible for payment, and I cannot appeal to see if
Medicare would pay.
PGXL Laboratories will not report or bill any
test in the above list that does not have a
fully correct and executed ABN.
Patient Responsibility
PGXL will send the patient two
bills. PGXL expects the patient
to pay the balance that is due
for the testing provided. The
price list for each test is on
www.pgxlab.com/abn.
The ABN policy will take full effect as of October 1,
2013. PGXL will use the next 45 days, to notify EM
of instances that fall short of the policy, so the field
is ready for the go-live date.
Coming up: New
requisition form details
Visit www.pgxlab.com/abn