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2434 Interstate Plaza Drive Hammond, IN 46324 8779372190 Anthem BC Advance Beneficiary Notice Patient Name Patient Number Mayor Date of Notice Mayor will only pay for services that it determines to
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An ABN form is an Advance Beneficiary Notice of Noncoverage form used in the healthcare industry to inform Medicare beneficiaries that Medicare is not expected to cover a particular service or item.
Healthcare providers who participate in the Medicare program are required to file an ABN form when they expect Medicare to deny payment for a specific service or item.
To fill out an ABN form, providers must include the specific service or item that Medicare is not expected to cover, provide a clear explanation of why Medicare may deny payment, and have the beneficiary acknowledge receipt of the form by signing and dating it.
The purpose of an ABN form is to inform Medicare beneficiaries upfront about services or items that may not be covered by Medicare, allowing them to make an informed decision about whether to proceed with the service or item at their own expense.
An ABN form must include the beneficiary's name, the specific service or item that Medicare may deny payment for, a clear explanation of why Medicare may deny payment, and the provider's information.
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