In what situation is it necessary for a provider to issue an ABN?

A provider must issue an Advanced Beneficiary Notice (ABN) when there is a likelihood that a service will be denied by Medicare. The ABN serves as a protective measure that informs the patient that Medicare may not pay for the service, and it allows the patient to decide whether to proceed with the service knowing they may be responsible for the costs if Medicare does not cover it. This ensures transparency between the provider and the patient regarding potential financial responsibility.

The issuance of an ABN is not required for all Medicare services, only for those where there is a reasonable expectation of denial based on Medicare's coverage guidelines. It is also not automatically necessary when a patient requests a service, as the service may still be covered. Emergency services have specific coverage criteria and may not require an ABN unless they fall into the category of likely denial. This specificity underlines the importance of assessing the individual service's likelihood of Medicare payment before deciding to issue an ABN.