Advanced Beneficiary Notice of Non-Coverage (ABN) Form Revised

September 2017

WSI recently revised the Advanced Beneficiary Notice of Non-Coverage (ABN) form, which a provider should use effective immediately. Revisions include general formatting changes and the addition of an “other” section, which allows a provider to identify other non-reimbursable services or items not previously listed on the ABN.

A provider may use the ABN form to inform an injured worker about the costs associated with services WSI may not cover. The ABN allows an injured worker to decide whether to obtain the service or item in question and to accept financial responsibility if WSI denies coverage. WSI recommends obtaining a signed ABN form prior to providing the following to an injured worker:

  • Services and items not allowed, or which exceed statutory limitations, per North Dakota Administrative Code (e.g. Game Ready, acupuncture, trigger point injections)
  • Medical equipment and supplies, which are no longer medically necessary but an injured worker wishes to keep or continue receiving
  • Services denied in advance by WSI's Utilization Review department or the claim adjuster
  • Upgrades to medically necessary services or items, which are not medically necessary (e.g. luxury eye glass frames or lenses options)

Use of the ABN form does not waive WSI’s requirement that a provider submit all charges related to a worker’s compensation injury to WSI for medical bill auditing. To bill charges for which a signed ABN is present, append modifier GA to each applicable bill line and submit to WSI  with medical documentation and the ABN form. WSI will review all charges and documentation to make the most appropriate payment determination for each charge. A provider may only bill a patient or other insurance when specified by WSI’s remittance advice reason codes.

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