What Medicare form is used to show charges to patients for noncovered services?

The Advance Beneficiary Notice (ABN) is the correct form used to inform Medicare beneficiaries about the potential noncoverage of services. It serves as a notification to patients that Medicare may not pay for certain services or items, and it offers patients the opportunity to make an informed decision regarding their healthcare. When a healthcare provider believes that a specific service might not be covered by Medicare, they are required to provide an ABN prior to the service being rendered.

The ABN must clearly outline the service in question, state why Medicare might find it not medically necessary, and inform the patient of their financial responsibility if they choose to go forward with the service. This helps protect providers from claims denials and ensures patients understand their potential out-of-pocket costs.

The other options do not serve the same purpose. For example, the HIPAA X 12/270/271 refers to electronic eligibility inquiries and responses but does not pertain to noncovered services. The acknowledgment of receipt of notice of privacy practices is related to patient privacy rights under HIPAA rather than billing. The assignment of benefits refers to the arrangement where a patient authorizes their insurance payment to be made directly to the provider, but it does not address coverage issues.