Advance Beneficiary Notice of Non-coverage (ABN) NOTE: If Medicare doesn’t pay for Laboratory Test below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the Laboratory Test below.Patient Name(Required) Medicare ID Number:(Required) Laboratory Test(Required) E8400 MYCO16 Panel $399 E8501 Ochratoxin A $250 E8502 Aflatoxin Group (B1,B2,G1,G2) $250 E8503 Trichothecene Group $250 E8510 Gliotoxin $250 E8512 Zearalenone $250 P5115 Mold Panel IgG $169 P5114 Mold Panel IgE $169 M8605 Aspergillus Species / Target $320 M8617 Candida Species / Target $480 Estimated Cost: 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 below about whether to receive the Laboratory Test listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. Options(Required) OPTION 1. I want the Laboratory Test listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the Laboratory Test listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don’t want the Laboratory Test listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Check only one box. We cannot choose a box for you.Additional InformationThis notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. Signature(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected] Δ
