Advanced Beneficiary Notice (ABN) Form to be Completed for Each Date of Service

November 2018

WSI requires a provider complete the Advanced Beneficiary Notice of Non-Coverage (ABN) form for each individual date of service.  When recommending a medical service that WSI may not allow, the ABN informs the injured worker of the estimated cost for the service.  This allows the injured worker to decide whether to receive the service and accept financial responsibility if WSI denies payment.

To identify a charge accompanied with a signed ABN, a provider should append modifier GA to each applicable bill line.  A provider should then submit the signed ABN along with the bill and medical documentation to WSI.  WSI will review for the most appropriate payment determination.  If WSI does not reimburse for the service, a provider may then bill an injured worker or other insurance as specified by WSI's remittance advice reason codes.

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