Healthcare Providers

ABN (Advance Beneficiary Notice) Form

Forms

Advance Beneficiary Notice (ABN) for Medicare Patients

ABN – English ABN – Spanish

Instructions for Completing Advance Beneficiary Notice of Noncoverage (ABN) for Medicare Patients

Medicare will pay for one routine screening Pap test every two years, and one high-risk screening Pap test every 12 months. Please note that an ABN form must be completely filled out and signed by the patient and attached to the requisition in order for the specimen to be processed for Medicare patients.

If an approved diagnostic ICD-10 code is provided on the requisition form, Medicare will cover the Pap test and no ABN is required.

For molecular microbiology test(s) (Chlamydia/Gonorrhea, HPV, and BD Affirm VPIII), please refer to Molecular Microbiology ICD-10 Codes for Medicare and All Insurances for the approved ICD-10 codes for molecular test(s). If the ICD-10 code(s) provided on the requisition is not listed on this, an ABN form must be filled out completely, signed by the patient and attached to the requisition in order for the specimen to be processed for Medicare patients.

Please follow the steps below for proper completion of the ABN:

Step 1: Please provide the patient’s full name and identification number as it appears on the Medicare identification card.
Step 2: Under Laboratory Test(s), check all the laboratory test(s) (Pap and/or molecular microbiology) ordered on the requisition.
Step 3: Present the ABN form to your patient and be sure that the patient reads it in its entirety and understands it.
Step 4: Have your patient personally select Option 1, Option 2, or Option 3.
Step 5: Once one of the options is selected, the patient must sign and date the form.
Step 6: Provide your patient with a copy of the signed ABN form and let the patient know that if there are any questions, he/she can call us or visit pcnm.com.
Step 7: Please attach the completed ABN form with the completed requisition for those test(s) that the patient has agreed to have processed.

If the ABN is not properly completed, as instructed above, and/or signed by the patient, the processing of the specimen will be delayed or even rejected.