Medicare ABN

Medicaid Advanced Beneficiary Notice of Noncoverage
Patient Name

First NameLast Name
Patient Identification Number
This form is to inform you of potential services and/or materials that Medicaid will not pay. If Medicaid doesn't pay for the items checked or listed in the box below, the services and/or materials are your financial responsibility. While Medicaid doesn't cover all services and/or materials, the items checked or listed in the box below are important for the health or your eyes.
The following services and/or materials are recommended for you, however, we expect Medicaid may not pay:

Comprehensive Eye Exam (price varies)Refraction 92015: $39.00Pachymetry 76514: $16.00Retinal Screening: $44.00Retinal Photos 92250: $82.00Visual Fields 92083: $101.00Gonioscopy 92020: $46.00OCT 92135: $98.00Vision Therapy: $632.00/blockNew Patient Vision Therapy Consultation: $241.00Intra Vision Therapy Consultation: $220.00Vision and Learning Consultation: $280.00Contact Lenses (price varies)Contact Lens services (price varies)Eyewear lenses (price varies)Eyewear frames (price varies)Emergency appointment (Sunday/Holidays) 99050: $125.00Emergency appointment (After Hours) 99051: $75.00Emergency appointment (Near Closing) 99058: $35.00Other
Reason Medicaid May Not Pay:

It is not covered in your contractNo documentation of medical problemIt is a screening testThe frequency limit is exceededNo proof of coverageOther
Total 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 checked items listed in the first box above.
Note: If you choose option 1 or 2, we may help you to use any other insurance that you might have, but Medicaid cannot require us to do this.
Please check only one option. We cannot choose an option for you.

Option 1: I would like to proceed with the services and/or materials listed above. You may ask to be paid now, but I also want Medicaid billed for an official decision on payment. I understand that if Medicaid doesn't pay, I am responsible for payment, but I can appeal to Medicaid. If Medicaid does pay, you will refund any payments I made to you, less co-pays and deductibles.Option 2: I would like to proceed with the services and/or materials listed above, but do not bill Medicaid. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicaid is not billed.Option 3: I don't want to proceed with the services and/or materials listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to Medicaid for payment.
This notice gives our medical recommendations, but it is not an official Medicaid decision. If you have other questions on this notice or Medicaid billing, call 1-800-324-8680 to contact the Ohio Medicaid Hotline.

Signing below means that you have received and understand this notice. Please let us know if you would like a copy.
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Medicaid Advanced Beneficiary Notice of Noncoverage