What is a Medicare ABN and when is it required?

An Advance Beneficiary Notice of Noncoverage (ABN) is a written notice given to Medicare beneficiaries before providing items or services that Medicare may not pay for. It's required when the provider believes Medicare will deny coverage due to lack of medical necessity, frequency limits, or other coverage rules. It must be given before services are rendered.

What happens if a provider doesn't give an ABN when required?

If a provider fails to issue a required ABN and Medicare denies the claim, the provider cannot bill the patient and must write off the charges. The provider is liable for the full cost. Proper ABN documentation shifts financial responsibility to the patient who chose to receive the service knowing Medicare might not pay.

What are the three options on the ABN form?

Option 1: Patient wants service and wants Medicare billed for a coverage decision (can appeal if denied). Option 2: Patient wants service but doesn't want Medicare billed (cannot appeal, must pay out of pocket). Option 3: Patient doesn't want the service (no billing occurs). The patient must choose one option before receiving service.

Can a patient sign an ABN after receiving services?

No. An ABN must be provided and signed before services are rendered for the provider to bill the patient if Medicare denies. A post-service ABN may be used for documentation but does not transfer liability to the patient. The only exception is if the ABN was properly delivered but the patient refused to sign.

What makes an ABN valid?

A valid ABN must: be the current CMS-approved form (CMS-R-131), be provided before the service, clearly describe the items/services, give a specific reason Medicare may not pay, include estimated costs, be signed and dated by the beneficiary, and give the patient time to consider options. Blank or incomplete ABNs are invalid.

Medicare ABN Form Template (CMS-R-131)

Advance Beneficiary Notice of Non-coverage (ABN) Notifier (Provider): [Practice Name, Address, Phone] Patient Name: [Patient Name] Identification Number: [Patient ID] * NOTE: If Medicare doesn't pay for the items or services 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 D. Items or Services listed below.

D. Items or Services	E. Reason Medicare May Not Pay	F. Estimated Cost
[Item 1, e.g., Lab Test]	[Reason, e.g., Not medically necessary for diagnosis]	$[Cost]
[Item 2]	[Reason, e.g., Frequency limit exceeded]	$[Cost]

* G. OPTIONS: Check only one box. We cannot choose a box for you. [ ] OPTION 1. I want the D. Items or Services 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 D. Items or Services 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 D. Items or Services listed above. I am not responsible for payment, and I cannot appeal to see if Medicare would pay. * 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-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

I. Signature: __________________________ J. Date: [Date] * CMS Disclosure:

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.

Medicare ABN Template: Advance Beneficiary Notice

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