A. Notifier:  MedFaxx, Inc. 
 
B. Patient Name:  ____________________________  
 
C. Identification Number:  Medicare Number: _____________________
 
 
MedFaxx Advance Beneficiary Notice of Noncoverage (ABN)
 
 
NOTE:   Medicare will pay for a tens unit, code E0730) for chronic pain.  The  Portable Infrex Plus Interferential  Machine,  below, has two modes, one is tens and the other is interferential.  The tens mode is covered by Medicare under the E0730 billing code. 
 
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 the full price for the D. Portable Infrex Plus Interferential  Machine   below. 
 
 
 D. Portable Infrex Plus Interferential  Machine
       
 
E. Reason Medicare May Not Pay:  Will declare "interferential therapy" as "experimental".  Interferential therapy has been used since 1953.  Medicare does pay for a tens machine. 
 
F. Infrex  Cost is:   $895.00  price
 
 
 
 
 
 
 
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 D. Portable Infrex Plus Interferential  Machine  listed above or a standard tens unit.  
 
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.
 
G. OPTIONS:     Check only one box.  We cannot choose a box for you.
 
☐ OPTION 1.  I want the D.   listed above.  Medfaxx may ask Medicare to be paid now for the tens unit, 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 the full price of an Infrex Plus,  but does pay for a tens unit,  that I am responsible for any additional balance due.  I can appeal to Medicare by following the directions on the MSN.   If Medicare does pay for the tens unit , you will credit  any payments Medicare made to you, less co-pays or deductibles toward the purchase price of the Infrex Plus at $895.00.  
 
☐ OPTION 2.   I want the   D.   listed above, but do not bill Medicare. You will ask to be paid now, or minimally $450 security deposit for the trial of the Infrex Plus.   I am responsible for payment in full if I decide to keep the Infrex Plus . I cannot appeal if Medicare is not billed.    
 
☐ OPTION 3. I don’t want the D.   listed above.  I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.  I understand I will be sent a tens unit, not the Infrex Plus unit. 
       
H. Additional Information:  
 
 
This notice gives our opinion, not an official Medicare decision.
 
 If you have other questions on this notice or Medicare billing, call 1-800-937-3993.    MedFaxx provides several videos and articles concerning this policy on the web site, http://www.medfaxxinc.com. 
 
Signing below means that you have received and understand this notice. You also receive a copy. 
 
 I. Signature:______________________________________
 
J. Date:       _______________________________________
 
   According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-0566.  The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
 
 If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to:
 
MedFaxx
Billing Compliance 
P.O. Box 1289
Wake Forest, N.C.  27588-1289