(The purpose of the ABN is to inform Medicare patients that Medicare will only pay for services that it deems "reasonable and necessary" and if the services performed are not covered under Medicare, the payment of these services then becomes the responsibility of the patient.)

The physician must explain to the patient why they feel that Medicare will not cover a particular service and the patient's responsibility if the testing is performed. The ICD-9 diagnosis code on the patient's test requisition (or doctor's order) must be consistent with the documentation in the patient's medical records for the same date of test request. If a patient's diagnosis is not an approved ICD-9 code, they will need to be informed that Medicare is likely to deny payment for their testing and they will be asked to sign the ABN. By signing the ABN the patient will accept the responsibility for payment of the services performed.

After the ABN has been thoroughly explained to the patient, the phyician must fill out the form completely with the name of the test, the reason the test may be denied and then have the patient read, sign, and date the notice. This notice must be sent to the laboratory with the requisition (or order).

Provider (Physician) Notice:

Medicare will only pay for services that it determines to be "reasonable and necessary" under section 1862 (a) (1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is not "reasonable and necessary" under the Medicare program standards, Medicare will deny payment for that service. I believe that in your case, Medicare is likely to deny payment for _____________________________(list particular service(s) for the following reasons: _________________________________________________________________________ _________________________________________________________________________

(specify the reason(s) you believe the services will be denied by Medicare)

Benificiary (Patient) Agreement:

I have been notified by my physician that he/she believes that, in my case, Medicare is likely to deny payment for the services identified above, for the reasons stated.  By signing the Patient Signature below, I am confirming my responsibility to assume financial responsibility for the payment of these tests.

Patient Signature ________________________________     Date _______________

Print, sign, and return ABN to Prostate Lab