Page 82 - R2P Front Desk Manual v1

Medicare ABN Intake Forms and Process

Overview: The ABN (Advance Beneficiary Notice of Noncoverage) is a notice given to
beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a
specific case. “Notifiers” - including physicians, providers, practitioners and suppliers paid under
Part B - issue the ABN to inform beneficiaries of potential liability.

Dry Needling ABN: Medicare does not cover Dry Needling. Patients will need to sign once and
select OPTION B prior to their first Dry Needling session, along with the Dry Needling consent
form. The patient will pay $25 PER Dry Needling session.
● Communication to the patient will be initiated by the Therapist during their plan of care
and finalized by the Clinic Coordinators.
○ Inform the patient that financial responsibility falls on them as Medicare does not
cover this procedure.
○ If the patient wants to proceed, the PT will walk them to the Front Desk to sign
the “ABN DN” form on the iPad.
● Once completed, forms will be automatically emailed to the specific clinic and should be
saved in the patient's chart.
○ Clinic Coordinators will make note to collect $25 per visit when Dry Needling
takes place (communicated from Therapist) and record as Internal Payment.

Wellness Plan ABN: Once deemed that treatment is no longer medically necessary or the
patient is approaching their cap, we will use the Wellness Plan ABN form. Patients will need to
sign the form once. We highly encourage the patient to select Option B and will collect $70
per visit and transition to a Self Pay case. The patient’s case will be monitored internally by
Clinical staff and Coordinators for proper timing of the Wellness Plan.
● Communication to the patient will be initiated by the Therapist during their plan of care
and finalized by the Clinic Coordinators.
○ Patients will be presented with and complete the ABN Wellness form on the
iPad as the Medicare Cap is approached or their treatment may be deemed not
medically necessary.
● Once completed, forms will be automatically emailed to the specific clinic and should be
saved in the patient's chart.
○ Clinic Coordinators will collect $70 per visit in a new Self Pay case and record
payment as Internal Payment.
○ The previous case billed to Medicare must be discharged by the Therapist.

Last Update: 7/10/19