• The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient.
The medical reason for performing this test does not meet medical necessity and the provider is expecting a denial. However, the provider did not give an ABN to the patient prior to performing the service.
• This modifier is an informational modifier only.
• Medicare will adjudicate the service just like any other claim.
• If Medicare determines that the service is not payable, denial is under a “medical necessity.” The denial message will indicate that the patient is not responsible for payment.
• If either the beneficiary or provider requests a review, the modifier tells us that an ABN was not given and this could help in completing the review quickly.