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New UHC ABN Requirements for Commercial & Medicare Advantage Plans Effective 4/1/2025
Effective April 1, 2025, UnitedHealthcare (UHC) will require the issuance of Advance Beneficiary Notices (ABNs) for all services rendered under our Commercial and Medicare Advantage (MA) plans when there is reason to suspect that the patient's benefits may not cover a particular service. This new protocol is essential to ensure compliance and protect both patients and providers.
Key Points to Note:
ABN Requirement for All Potentially Non-Covered Services:
Providers must obtain an ABN for any servicewhere there is reason to suspect that the patient's benefit plan may not cover the service. This includes services that may be considered not medically necessary, experimental, or otherwise excluded under the patient's specific benefits.
No Generic or Blanket Notices:
UHC will not accept generic written notices or blanket notices. Each ABN must be specific to the service in question and to the patient’s benefits. The ABN must clearly inform the patient of their potential financial responsibility.
Additional Requirements for Medicare Advantage Plans:
MA plans have additional required componentsthat must be included in the ABN. Please refer to the attached notification for full details on these specific requirements.
Modifiers and Service Documentation:
Providers must ensure that they append the appropriate modifier to services that are identified as potentially non-covered under the patient's benefit plan. The attached document outlines the specific modifiers that must be used. This step is crucial for accurate billing.
Preservice Determination Recommendation:
To avoid delays and issues, we highly recommend obtaining a preservice determination via the UHC Provider Portal for all patients with suspected non-covered services prior to performing any procedures. This can help ensure clarity regarding coverage and mitigate any potential issues with claims.
Failure to Follow Protocol:
Please be advised that if the ABN process is not followed correctly, Providers will not be able to bill the member for non-covered services. Compliance with this protocol is critical to avoid any billing discrepancies and to ensure that patients are properly informed of their financial responsibility.
Next Steps:
• Review the attached ABN reference guide.
• Ensure all staff are trained on these new requirements.
• Begin implementing these procedures on April 1, 2025.
Should you have any questions or need additional clarification regarding the workflow process, please feel free to reach out to our Central Billing Office (CBO) for assistance at 877-856-3774. Thank you for your attention to this important update. We appreciate your partnership in ensuring the proper handling of claims and maintaining high standards of patient care.
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