CMS Pub. 100-04, ch. 30, § 50.12

Act

(Rev. 10862; Issued: 07-14-21; Effective: 10-14-21; Implementation: 10-14-21)

A. Mandatory

A request for an advance determination of coverage of medical equipment and supplies is

mandatory under §1834(a)(15)(C)(i) & (ii) of the Act when:

• The item is listed by the Secretary as being subject to unnecessary utilization in your

contractor’s service area under §1834(a)(15)(A); or

• The supplier is listed by the Secretary under §1834(a)(15)(B) of the Act as a supplier

who has submitted a substantial number of claims, which have been denied as not

medically reasonable and necessary under §1862(a)(1) of the Act or the Secretary has

identified a pattern of over utilization.

In cases in which an advance coverage determination is mandatory, an ABN must be

issued to the beneficiary prior to furnishing the item. If the advance coverage

determination has not been received, or if the determination is that Medicare will not pay

for the care, an ABN is required prior to furnishing the requested item.

B. Optional

A request for an advance determination of coverage of medical equipment and supplies is

optional under §1834(a)(15)(C)(iii) of the Act when the item is customized and either the

beneficiary or the supplier requests an advance determination. In cases where an advance

coverage determination is optional and the beneficiary requests such a determination, an

ABN must be furnished prior to furnishing the requested item.

Every supplier is expected to know whether or not an advance coverage determination is

required for Medicare payment. The presumption of that supplier’s knowledge becomes

non-rebuttable after a single denial under §1834(a)(15) of a claim by a particular supplier.