Advance Beneficiary Notice of Noncoverage (ABN) documents and the organization determination (OD) notice of denial

ABN documents

Providers should be aware that an ABN document is not a valid denial notice for a Medicare Advantage member. The Original Medicare program uses ABN documents — sometimes called “waivers.” But you can’t use them for patients in Aetna Medicare Advantage plans, since the Centers for Medicare & Medicaid Services (CMS) prohibits them.

What Aetna Medicare Advantage plans cover

Providers in the Medicare program should know which services Original Medicare covers and those it does not.

Aetna Medicare Advantage plans must cover everything Original Medicare does. In some cases, they may provide coverage that is more generous or benefits that go beyond what’s covered by Original Medicare. We urge you to call us to verify coverage or for answers to other questions you might have.

Organization determination (OD) notice of denial

Providers in Medicare Advantage plans can’t charge a Medicare Advantage member for a service not covered under their plan unless that member gets a preservice OD notice of denial from us before getting such services. If the member does not have a preservice OD notice of denial from us, you must hold the member harmless for the noncovered services. You can’t charge them any amount beyond the normal copayments, coinsurance and deductibles.

If a service is never covered under Original Medicare or is a clear exclusion in the plan documents, a preservice OD isn’t needed. You may hold the member financially liable for such noncovered services. Note that services or supplies that are not medically necessary or are not covered in the clinical criteria are not “clear exclusions.” In such cases, the member isn’t likely to know if a service is medically necessary.

You or the member can initiate an OD notice of denial. This will help determine if the member has coverage for a service before they receive care. This will also help everyone know the status of benefits before setting up a lab or diagnostic test.

You’ll be able to hold an Aetna Medicare member financially responsible for a noncovered service only if:

• A service or supply is never covered under Original Medicare
• The member has a preservice OD notice of denial from Aetna® and decides to proceed with the service knowing they will have to pay the full cost