Advance Beneficiary Notice (ABN) Noncovered Service Discussion Note

Date/Time of Discussion: [Date and time]

Setting: [telehealth / in-person / phone]

Author/Role: [Name, credentials, and role]

Patient Present: [Yes / No]

Representative Present: [Name, relationship, and authority basis if applicable / None]

Interpreter Used: [Yes / No; if yes, language and modality]

Payer Status: [Medicare FFS / Medicare Advantage / Other]; [Secondary insurance if known]; [Note if uncertain and basis for determination]

Service(s) and Noncoverage Rationale

(Repeat the following for each service/item discussed.)

• Service: [Patient-friendly service name and clinical descriptor]
• Planned date: [Date or date range]
• Ordering/referring clinician: [Name and role / Not applicable]
• Noncoverage category: [medical necessity concern / frequency limitation / experimental-investigational / statutory exclusion / custodial-non-skilled / other: specify]
• Policy basis: [LCD/NCD name or ID and specific criterion not met / Plan policy reference / Unknown—verification pending]
• Patient-specific facts: [Diagnosis/indication alignment, prior utilization dates, prerequisites not met, or other applicable facts]
• Level of certainty: [likely noncovered / possibly noncovered]

ABN Process and Financial Counseling

• ABN applicability: [Yes—mandatory / Yes—voluntary courtesy / No—not applicable]; Rationale: [Payer context and coverage expectation]

(If ABN is applicable, complete the following. If not applicable, document alternative counseling provided below.)

• ABN delivered: [Yes / No]; Date/Time: [Date and time]
• Delivery method: [in-person / phone with follow-up / mail / secure fax-email]
• Delivered by: [Name and role]; Recipient: [Patient / Representative name and relationship]
• Reviewed and questions addressed before signature: [Yes / No]
• Copy provided to patient/representative: [Yes / No]
• Emergent/urgent consideration: [Not applicable / Reason ABN not delivered and post-stabilization counseling summary]

Financial Counseling:

• What may be denied and why: [Service(s) and reason in plain language tied to policy/facts]
• Estimated out-of-pocket cost: [$ amount / Pending—awaiting price quote]
• Alternatives discussed: [Defer until criteria met / Alternative covered service / Different timing or location / None]
• Patient questions and answers provided: [Summary of questions and counseling / None]
• Comprehension confirmed: [Teach-back statement or patient verbalization / Not obtained] (Do not infer understanding; document only if explicitly confirmed.)

Patient Decision and Plan

• Option selected: [Option 1 / Option 2 / Option 3 / None—patient declined to choose] (Record exactly as selected.)
• Signature obtained: [Yes / No]; Date: [Date]; Type: [electronic / wet]
• If refused to choose or sign: [Refusal circumstances]; Witness: [Yes/No; name and role]; Service provided: [Yes / No]; Rationale: [Clinical or operational reason]
• Decision: [Proceed / Defer / Decline]

If Proceeding: [Performed today / Scheduled date]; Prepayment: [$ amount / None]; Claim submission: [Submit per selected option / Do not submit—self-pay]

If Deferring: [Follow-up plan with responsible party and timeframe]; ABN status: [Pending signature / Signed—effective through date]

If Declining: [Patient acknowledgment of clinical consequences if discussed]; Alternative plan: [Details / None offered or accepted]

ABN Storage: [Yes—stored in EHR location / Pending—owner and due date]; Repetitive services: [Date range covered and next ABN required / Not applicable]

(Use explicit placeholders for missing information. Do not infer understanding, signatures, or option selections—document only what is explicitly confirmed.)