Commercial insurance does not pay for everything, even some care that you Read this notice, so you can make an informed decision about your care - Ask us
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Notifier(s):
Patient Name:
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
NOTE: If your insurance carrier, ____________________________, doesnt pay for items listed in the box below, you may have to pay. Commercial insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect your carrier may not pay for the items listed or checked below.Listed Items: Reason Insurance May Not Pay: Estimated Cost:
CV Profile (93922) - Investigational/Unnecessary $ 300.00
T-Wave Alternans (93025) - Investigational/Unnecessary $ 1,000.00
Bio Z (93701) - Investigational/Unnecessary $ 160.00
EECP (92971) - Investigational/Unnecessary $ 700.00
Blood Pressure Monitor - Not a covered Benefit $ 245.00
What you need to do now:
- Read this notice, so you can make an informed decision about your care. - Ask us any questions that you may have after you finish reading. - Choose an option 1 or 2, we may help you to use any other insurance that you might have, but your carrier cannot require us to do this. Options: Check only one box. We cannot choose a box for you. ____ OPTION 1. I want the test listed above. Yu may ask to be paid now, but I also want mycarrier billed for an official decision on payment, which is sent to me on an Explanation of Benefits
(EOB). I understand that if my insurance doesnt pay, I am responsible for payment, but I can appeal to my carrier by following the directions on the EOB. If my carrier does pay, you will refund any payments I made to you, less co-pays or deductibles. ____ OPTION 2. I want the test listed above, but do not bill my insurance. You may ask to be paid now as I am responsible for payment. I cannot appeal if my carrier is not billed. ____ OPTION 3. I dont want the test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if my carrier would pay.This notice gives our opinion, not an official Carrier decision. If you have other questions on this
notice or billing, call your carrier at the number listed on the back of your ID card. Signing below means that you have received and understand this notice. _________________________________________ ____________________________________ Signature Datequotesdbs_dbs11.pdfusesText_17