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Advance Beneficiary Notice of Non-coverage Tutorial

What’s Changed?

  • Updated resources with a link to the Beneficiary Notices Initiative (BNI) Library webpage

Use this educational tool by selecting the tabs above or scrolling to each section.

Using the ABN Tutorial

Select any field (letters A–J) for details on how to complete each ABN section.

Quick Start

The Advance Beneficiary Notice of Non-coverage (ABN), Form (CMS-R-131) helps Medicare Fee-for-Service (FFS) beneficiaries make informed decisions about items and services Medicare usually covers but may not cover in specific situations. For example, the items or services may not be medically necessary for a beneficiary.

When health care providers and suppliers expect a Medicare coverage denial for a service Medicare generally covers, they must issue an ABN to transfer financial liability to the beneficiary, including:

  • Independent labs, Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) providing Medicare Part B (outpatient) items and services
  • Hospice providers, HHAs, and Religious Non-Medical Health Care Institutions providing Part A (inpatient) items and services

This educational tool shows health care providers and suppliers how to correctly complete an ABN form. In this ABN tutorial, you refers to the provider or supplier issuing the form. On the ABN form, you refers to the beneficiary signing it.



You must issue an ABN:

  • When a Medicare item or service isn’t reasonable and necessary under Program standards, including care that’s:
    • Not indicated for the diagnosis, treatment of illness, injury, or to improve the functioning of a malformed body member
    • Experimental and investigational or considered research only
    • More than the number of services allowed in a specific period for that diagnosis
  • When providing custodial care
  • When outpatient therapy services exceed therapy threshold amounts
  • Before caring for a beneficiary who isn’t terminally ill (hospice providers)
  • Before caring for a beneficiary who isn’t confined to the home or doesn’t need intermittent skilled nursing care (home health providers)
  • Before providing a preventive service we usually cover but won’t cover in specific situations when services exceed frequency limits
  • Before providing a Medicare item or service we won’t cover (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies [DMEPOS] suppliers) because:
    • Provider accepted prohibited unsolicited phone contacts
    • Supplier hasn’t met supplier number requirements
    • Non-contract supplier provides an item listed in a competitive bidding area
    • Beneficiary wants the item or service before the advance coverage determination

We may hold you financially liable if you don’t give the beneficiary an ABN for 1 of these specific situations.

Don’t use an ABN for Medicare Advantage (Part C) items and services or the Medicare Prescription Drug Benefit (Part D).

You don’t need to notify the beneficiary before you provide items or services that aren’t a benefit or never covered. Section 20.2 of the Medicare Claims Processing Manual, Chapter 30 has a list of Medicare non-covered items and services.

We recommend you issue a voluntary ABN or a similar notice as a courtesy to alert the beneficiary about their financial liability.

An ABN is valid if you:

  • Use our most recent version approved by the Office of Management and Budget (OMB)
  • Use a single ABN for an extended course of treatment for no longer than 1 year
  • Complete the entire form
  • Ensure the beneficiary understands the notice

What if the Beneficiary or their Representative Refuses to Choose an Option or Sign the ABN?

If the beneficiary or their representative refuses to choose an option or sign the ABN, you should note that on the original ABN. You may list refusal witnesses, but it’s not required. If a beneficiary refuses to sign a correctly issued ABN, consider not providing the item or service unless the consequences (health and safety of the beneficiary or civil liability in case of harm) prevent it.


ABN Tutorial

In this ABN tutorial, select any field (letters A–J) for details on how to complete each ABN section.

Entities who issue ABNs are collectively known as “notifiers.” Notifiers can include physicians, practitioners, providers (including labs) and suppliers, and utilization review committees.

If you reproduce the ABN, remove the letters before issuing it to the beneficiary.

A. Notifier(s)

  • You must place their name, address, and phone number (including TTY number, when needed) at the top of the notice. You may add this information to your logo at the top of the notice by typing, hand-writing, pre-printing, using a label, or other means.
  • If you and the billing entity aren’t the same, you may list more than 1 entity in the Header if it’s specified in the Additional Information (H) section who we should contact with billing questions.

B. Patient Name

  • You must enter the beneficiary’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 beneficiary or representative recognizes the name listed on the notice as the beneficiary’s.

C. Identification Number

  • This field is optional. If there’s no identification number, it doesn’t invalidate the ABN. You may enter a beneficiary 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 Medicare Beneficiary Identifiers (MBIs) or SSNs on the notice.

First ABN D. Field

List 1 of these descriptors:

  • Item
  • Service
  • Lab test
  • Test
  • Procedure
  • Care
  • Equipment

Second ABN D. Field

Use the same wording used in the first (D) field.

Third ABN D. Field

Use the same wording used in the first (D) field.

First D. Column

  • The notifier must list the specific items or services they believe we won’t cover in the blank (D) column
  • In a partial denial case, you must list the item’s or service’s excess component(s) for which denial is expected in the blank (D) column.
  • Put general descriptions of specifically grouped supplies in this column. For example, wound care supplies is enough to describe an item group. We generally don’t require an itemized list of each supply.
  • When you reduce a service, you must provide enough information so the beneficiary understands why. 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.
  • You must complete all 7 blank (D) fields to validate the notice. We encourage you to populate all blank (D) fields before using a general descriptor like Item(s) or Service(s).

E. Reason Medicare May Not Pay

In this column, notifiers must explain, in beneficiary friendly language, why they believe Medicare may not cover the items or services in column (D). Three non-coverage reasons we commonly use:

  • We don’t pay for this test for your condition
  • We don’t pay for this test this often (denied as too frequent)
  • We don’t pay for experimental or research tests

To be a valid ABN, you must list at least 1 reason for each item or service in column (D). You can use the same non-coverage reason for multiple items in column (D) when appropriate.

F. Estimated Cost

  • Notifiers must complete column (F) to ensure the beneficiary has all available information 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 column (D). We expect the estimate be within $100 or 25% of actual costs, whichever is greater; generally, we accept estimates exceeding the actual cost, since it won’t harm the beneficiary 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 (BMP). We accept an average daily cost estimate for long-term or complex projections.
  • You may also pre-print a menu of items or services in column (D) and include a cost estimate beside each item or service. If a situation calls for additional tests or procedures (such as lab reflex testing), and you can’t reasonably estimate those test costs at ABN delivery, you may enter the initial cost estimate and indicate possible further testing.
  • If you can’t provide a good faith projected cost estimate at ABN delivery, you may indicate in the cost estimate area there’s no cost estimate available. You shouldn’t use these last 2 scenarios routinely or frequently, but the beneficiary has the option of signing the ABN and accepting liability in these situations.

G. Options

Complete the 3 (D) fields under the (G) Options section with the same wording used in the first (D) field. The beneficiary, or their representative, must choose 1 of the 3 options listed. We don’t allow you to make this selection.

Special guidance for people who are dually enrolled in both Medicare and Medicaid, also known as dually eligible individuals (has a Qualified Medicare Beneficiary [QMB] Program and or Medicaid coverage), ONLY:

Instruct them to check ABN Option Box 1 so the notifier can submit the claim for Medicare adjudication. Strike through Option Box 1 language as shown here:

OPTION 1. I want the D._______ 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.

We require these edits because the notifier can’t bill the dually eligible beneficiary when they offer an ABN. You must not bill the beneficiary pending Medicare and Medicaid adjudication, because federal law affects dually eligible beneficiary coverage and billing.

If we deny a claim when you needed an ABN to transfer financial liability to the beneficiary, 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 only charge the patient in these circumstances:

  • If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow you to shift financial liability to the beneficiary per Medicare policy
  • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow you to shift financial liability to the beneficiary per Medicare policy, subject to state laws that limit beneficiary liability

Note: The beneficiary 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 beneficiary wants to get the items or services listed and accepts financial responsibility if we don’t pay. They agree to pay now, if required. Notifiers must submit a claim to Medicare that results in a payment decision the beneficiary can appeal. If they need a Medicare claim denial for secondary insurance to cover the service, you may advise them to select Option 1.

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

Strike the last Option Box 1 sentence as shown here:

OPTION 1. I want the D. ___________ listed above. You may ask for payment now, but I also want Medicare billed for an official decision on payment, sent to me, on a Medicare Summary Notice (MSN). I understand if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the MSN directions. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

Notifiers, include this single line strike on ABNs printed specifically when you provide unassigned items and services. You can also hand-pen the line on an already-printed ABN. Don’t entirely conceal or delete the sentence. We don’t require you or beneficiaries to initial beside the sentence or date the annotations when you make the changes.

When you strike this sentence, you should include this CMS-approved unassigned claim statement in the (H) Additional Information section:

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

You can include this statement on ABNs printed for unassigned items and services, or hand-write it in a legible 10 point or larger font.

Fourth ABN D. Field

Use the same wording used in the first (D) field.

Fifth ABN D. Field

Use the same wording used in the first (D) field.

Sixth ABN D. Field

Use the same wording used in the first (D) field.

Option 2

The beneficiary wants to get the item or services listed and accepts financial responsibility. They agree to pay now, if required. When the beneficiary chooses this option, you don’t file a claim, and there are no appeal rights.

You won’t violate mandatory claims submission rules under section 1848 of the Social Security Act when you don’t submit a claim at the beneficiary’s written request.

Option 3

The beneficiary doesn’t want the care in question and you can’t charge them for items or services listed. You don’t file a claim, and there’s no appeal right.

H. Additional Information

Notifiers may use this space to clarify what they believe is useful to beneficiaries. You may use this space to include:

  • Statement advising the beneficiary to notify their provider about certain ordered, but not received tests
  • Information on other beneficiary insurance coverage, like a Medigap policy
  • An additional dated witness signature
  • Other necessary annotations

We assume notifiers made annotations on the same date that appears in field (J), accompanying the signature. If they made the annotations on different dates, make those dates part of the annotations.

I. Signature

The beneficiary (or representative) must sign the notice to indicate they got the notice and understand its contents. If a representative signs for a beneficiary, they should write out representative in parentheses after their signature. The representative’s name should be clearly legible or noted in print.

J. Date

The beneficiary (or representative) must write the date they signed the ABN. If the beneficiary has physical difficulty writing and requests assistance completing this field, the notifier may write the date.



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