Advance Beneficiary Notice of Non-coverage Tutorial Print Back to MLN April 2026 Updates

Patient name

You must enter the patient’s first and last name and include a middle initial if it appears on their Medicare card. We won’t invalidate the ABN because of a misspelling or missing initial if the patient or representative recognizes the name listed on the notice as the patient’s.

Identification number

This field is optional. Having no identification number doesn’t invalidate the ABN. You may enter a patient identification number that links the notice with a related claim, and you may create an internal filing number, like a medical record number. Don’t list MBIs or SSNs on the notice.

Notifier name, Notifier address, Notifier phone (including TTY)

You must place the notifier’s name, address, and phone number (including TTY number, when needed) at the top right of the notice. You can add this information to your logo at the top of the notice by typing, writing, preprinting, using a label, or other means.

If you and the billing entity aren’t the same, you can list more than 1 notifier if you specify in the Additional Information section whom we should contact with billing questions.

Item, test, service or care

You must list the specific item, test, service, or care you believe we won’t cover in the first blank column.

In a partial denial case, you must list the excess components of the item, test, service, or care you expect we’ll deny.

Put general descriptions of specifically grouped supplies in this column. For example, “wound care supplies” is enough to describe a group of items used to provide this care. We generally don’t require an itemized list of each supply.

When you reduce a service, you must provide enough information for the patient to understand what’s being reduced. For example, we consider “wound care supplies decreased from weekly to monthly” enough to describe a frequency decrease for this supply category; just writing “wound care supplies decreased” isn’t enough.

Reason Medicare may not pay

In this column, you must explain, in patient-friendly language, why you believe we may not cover the listed items, tests, services, or care. Three common non-coverage reasons are:

• Medicare doesn’t pay for this test for your condition
• Medicare doesn’t pay for this test this often (the test is denied as too frequent)
• Medicare doesn’t pay for experimental or research use tests

For the ABN to be valid, you must list at least 1 reason for each item or service in the “Item, test, service or care” column. You can use the same non-coverage reason for multiple items when appropriate.

Estimated cost

You must complete the “Estimated cost” column to ensure the patient has all the information they need to decide whether to get potentially non-covered services.

You must make a good faith effort to list a reasonable dollar estimate for all items or services in the “Item, test, service or care” column. However, we generally accept estimates that substantially exceed the actual cost, since it won’t harm the patient if actual costs are less than predicted.

Notifiers can bundle routinely grouped items or services into a single cost estimate. For example, you may give a single cost estimate for a group of lab tests, like a basic metabolic panel. We accept an average daily cost estimate for long-term or complex projections.

You may also preprint a menu of items or services in the “Item, test, service or care” column and include a cost estimate beside each item or service.

If a situation involves possible additional tests or procedures (like lab reflex testing) and you can’t reasonably estimate those test costs at the ABN delivery, you may enter the initial cost estimate and indicate possible further testing. If you can’t reasonably estimate the cost at the ABN delivery, you may indicate in the “Estimated cost” column that no cost estimate is available. Although you shouldn’t routinely omit cost estimates, the patient has the option of signing the ABN and accepting liability in these situations.

Choose ONE option below. We can’t choose for you.

The patient, or their representative, must choose 1 of the 3 options listed. We don’t allow you to make this selection for them. If the patient is physically unable to enter their selection, you may do so for them and annotate the notice to indicate this happened.

Special guidance for people who are dually enrolled in both Medicare and Medicaid (have Qualified Medicare Beneficiary (QMB) Program or Medicaid coverage) ONLY:

You must instruct the patient to check ABN Option Box 1 so you can submit the claim for Medicare adjudication. Strike through Option Box 1 language as shown here:

□ OPTION 1. I want the item, test, service or care listed above, and I want Medicare to be billed for an official decision on payment, which I’ll get on a Medicare Summary Notice (MSN). You can ask to be paid now. I understand that if Medicare doesn’t pay, I’m responsible to pay, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you’ll refund any payments I made to you, minus co-pays or deductibles.

We require these edits because you can’t bill dually eligible patients, pending Medicare and Medicaid adjudications, when you offer an ABN. This is because federal law affects dually eligible patient coverage and billing.

If we deny a claim when you needed an ABN to transfer financial liability to the patient, cross the claim over to Medicaid or submit it for adjudication based on state Medicaid coverage and payment policy. Medicaid will issue a remittance advice based on this determination. Once Medicare and Medicaid adjudicate the claim, you may charge the patient only in these circumstances:

• If the patient has QMB coverage without full Medicaid coverage
• If the patient has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), subject to state laws that limit patient liability

Note: The patient doesn’t need to check an option box or sign and date the notice when you issue the ABN as a voluntary notice.

Option 1

The patient wants to get the item, test, service, or care listed and accepts financial responsibility if we don’t pay. They agree to pay now, if required. You must submit a claim to Medicare that results in a payment decision the patient can appeal. If the patient needs a Medicare claim denial for secondary insurance to cover the service, advise them to select Option 1.

Option 2

The patient wants to get the item, test, service, or care listed and accepts financial responsibility. They agree to pay now, if required. When the patient chooses this option, you don’t file a claim and they don’t have appeal rights.

When the patient requests in writing that you not submit a claim, you don’t violate mandatory claim submission rules under section 1848 of the Social Security Act by not submitting one.

Option 3

The patient doesn’t want the item, test, service, or care in question, and you can’t charge them for items, tests, services, or care listed. You don’t file a claim, and the patient doesn’t have the right to appeal.

Additional information

You can use this space to clarify what you believe is useful to patients. You may include:

• A statement advising the patient to notify their provider about certain tests that were ordered but the patient didn’t get
• Information on other patient insurance coverage, like a Medigap policy
• An additional dated witness signature
• Other necessary annotations

We assume you make annotations on the same date that appears on the signature line. If you make annotations on different dates, make those dates part of the annotations.

Special guidance for non-participating suppliers and providers (those who don’t accept Medicare assignment) ONLY:

Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you’ll refund any payments I made to you, minus co-pays or deductibles.

You can’t entirely conceal or delete this sentence; you must strike it. When you strike this sentence, include this CMS-approved unassigned claim statement in the “Additional Information” section:

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I’m responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

You can include this statement on ABNs printed for unassigned items and services, or you can legibly handwrite it.

Signature

The patient (or their representative) must sign the notice to indicate they got it and understand its contents. The signature should be in cursive, with printed annotation if needed to be understood. If a representative signs for the patient, they should write “representative” in parentheses after their signature. The representative’s name should be clearly legible or noted in print.

Date

The patient (or their representative) must write the date they signed the ABN. If the patient has physical difficulty writing and requests help with completing this field, you may write the date for them.