Understanding the correct use of the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 is important to ensure billing compliance for traditional Medicare (Part B). Audiologists may face challenges determining when Medicare covers a service and when an ABN is required. Federal law requires that providers, including audiologists, must notify a Medicare beneficiary in advance when a service that Medicare typically covers is likely to be denied and/or when the item or service is not considered by Medicare to be medically reasonable and necessary. The ABN meets this requirement.

For the public at large, Medicare evokes the concept of a health insurance plan for the aged or retired population. Created in 1965 to provide a safety net for older individuals who faced substantial medical problems, the benefits available to Medicare beneficiaries are generally more limited than those available through private health insurance plans. Medicare has four parts (Medicare.com, 2018) as summarized in Table 1.  

Under the final Quality Payment Program (QPP) rule for 2019, the Centers for Medicare and Medicaid Services (CMS) announced that audiologists will be considered “eligible clinicians” for QPP participation, effective January 1, 2019. The QPP replaced the Sustainable Growth Rate (SGR) formula that for many years served as the underpinning of Medicare provider payment.