An ABN is a written notice from Medicare (standard government form CMS-R- 131), given to you before receiving certain items or services, notifying you: -Medicare may deny payment for that specific procedure or treatment -You will be personally responsible for full payment if Medicare denies payment. -It also offers you the right to appeal Medicare’s decision. Although Medicare may not pay for your items or services, there may be good reasons for your physician recommending them. You should notify your doctor of your refusal.

You have the option to receive the items or services or to refuse them. In either case, you should choose one option on the form by checking the box provided, and then signing and dating it in the space provided. If you choose to receive the items or services and want Medicare billed: You must check “OPTION 1”. Sign and date the form. The claim will be sent to Medicare. You may be billedwhile Medicare is making its decision. If Medicare does pay, you will be refunded anypayments that are due to you. If Medicare denies payment, you will be personallyresponsible for full payment. You will have the right to appeal Medicare’s decision. If you choose to receive the service but do NOT want to bill Medicare: You must choose “OPTION 2” Sign and date the form The claim will not be sent to Medicare. Secondary insurance will usually not pay, so youwill be responsible for paying the account in full. You will not be able to appeal Medicare because itwas not billed to them. If you choose NOT to receive the items or services: You must check “OPTION 3” Sign and date the form.

If you refuse to sign, one of two actions will take place: McGehee Hospital may decide not to provide the items or services. A second person will witness your refusal to sign the agreement, and you will receive the items or services. However, you may be held liable because you have been notified of the likelihood of a Medicare denial. If you still want to receive services. We may ask for payment in full. We may ask for a down payment on date of service. A promissory note will need to be signed by you. The payment arrangements made will be need to be followed, otherwise your balance will be forwarded to collections after 4 months.

When you sign an ABN and become liable for payment, you will have to pay for the total charge amount of the item or service yourself; either out of pocket or by some other insurance coverage that you may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between you and McGehee Hospital. *We may set up a payment plan

Certain items or services that are covered by Medicare are only covered up to a certain number of times within a specified amount of time. Examples of these “frequency limited” services include laboratory tests, some preventive screening tests and vaccinations. If you receive an ABN that gives a frequency limit as its reason, it means that Medicare will not pay if you exceed that limit on the service.

No. ABNs do not operate to reduce coverage at all. Only if you choose “OPTION 1” and when Medicare does deny the claim, do you become liable for paying personally for the service or item. If Medicare decides to pay the claim, you have lost nothing by signing the ABN.

For more information about your Medicare coverage, please contact Medicare directly: Phone: 800-633-4227 (toll-free) Website: www.medicare.gov