Submit this form to your Medicare Administrative Contractor via mail, fax, or online portal. For mailing, use the address found on your MAC's website. Fax submissions should go to the toll-free fax number provided by your MAC, and ensure to keep a copy of the submitted form for your records.

Important dates for this form in 2024 include the implementation of updates effective May 15, 2024. Subsequent changes may occur in 2025, ensuring compliance with Medicare guidelines. Be sure to check back for any updates.

This form serves to notify beneficiaries about noncovered services under Medicare. It provides healthcare providers with the necessary instructions on issuing Advance Beneficiary Notices. By using this form, providers can ensure compliance and accurate billing practices within the Medicare system.

• 1. MLN Matters® Number: This number identifies the specific article related to the guidelines.
• 2. Effective Date: The date the guidance becomes effective for implementations.
• 3. Provider Types Affected: Identifies which types of providers need to adhere to the guidelines.
• 4. Key Points: Summarizes the essential points regarding the Advance Beneficiary Notice.
• 5. Additional Information: Provides further details on the guidelines and links to resources.

Failing to submit this form may lead to noncompliance with Medicare regulations. Providers could face repercussions such as audits or reimbursement denials due to improper notice issuance.

• Compliance Issues: Non-submission risks violation of Medicare guidelines.
• Financial Losses: Failure to issue notices may lead to unpaid claims.
• Reputation Risks: Providers may be viewed as negligent without proper documentation.

• 1. When Anticipating Noncoverage: Utilize this form to notify beneficiaries prior to providing services.
• 2. For Dual Eligible Beneficiaries: Use when dealing with beneficiaries who have both Medicare and Medicaid.
• 3. In Compliance Audits: Necessary for documentation during Medicare audits to prove proper notification was given.