601 Suffolk Avenue
Brentwood, New York 11717

Medicare Advance Beneficiary Notice

Medicare "Advance Beneficiary Notice (ABN)": Long Island Ambulatory Surgery Center provides the Medicare waiver or "Advance Beneficiary Notice" form. If you are given the ABN, please read carefully. Although Medicare may not pay for your items or services, there may be good reasons for your physician recommending them. Please allow us to assist by answering your questions. You should ask questions regarding your condition and why the tests are being requested by your provider. The ABN serves as proof that the beneficiary had knowledge prior to receiving a service or item that Medicare might not pay. www.hhs.gov

  1. What is an ABN? An ABN provides you the opportunity to accept or refuse certain items or services. An ABN is a written notice required from Medicare (government form OMB No.0938-0566), given to you before you receive certain services or items, notifying you:
  • that Medicare may deny payment
  • the reason Medicare may deny payment
  • and that you will be personally responsible for full payment if Medicare denied payment
  1. Why does my physician or supplier routinely give me an ABN? Physicians and suppliers may routinely issue ABNs for services or items that are covered by Medicare, but that are only covered up to a certain number of times within a specified amount of time.
  • Examples of "frequency limited" services include visual field testing, scanning laser tests, and photographs that Medicare will not pay if you exceed that limit on the service.
  1. If I receive an ABN, what are my options? You have the option to receive the service or to refuse them. In either case, you should choose on option on the form by checking the box provided, and then signing and dating it in the space provided
  2. What if I refuse to sign the ABN but I want the service or item anyway? Your provider may decide not to provide the service or item to you. You may have a second person witness your refusal to sign the agreement and then receive the treatment. If the ABN is witnessed, you may be held responsible for payment because you are on notice of the likelihood of a Medicare denial. Your physician or supplier may not provide the service or item to you if you refuse the sign the ABN and agree to be responsible for payment.
  3. Who can help me if I have specific questions about what Medicare covers? The Medicare Helpline is 1-800-486-2048 or you may visit online at HHS.gov.

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