Quick Answer
An Advance Beneficiary Notice (ABN) is a written notice your healthcare provider must give you before providing a service or item they believe Medicare may not cover. It gives you the choice to receive the service and accept financial responsibility, or to decline it.
Coverage Comparison by Plan Type
| Plan Type | Coverage | Notes |
|---|---|---|
| Original Medicare (Part A & B) | ABN Required | Providers must issue ABN before non-covered services |
| Medicare Advantage (Part C) | Similar Notice | MA plans use a different form (NEMB) but same concept applies |
| Medicare Part B Services | Most Common | ABNs are most frequently issued for Part B outpatient services |
| Durable Medical Equipment | ABN Required | DME suppliers must issue ABN if Medicare may deny the claim |
Understanding Your Coverage Options
What is an ABN?
An Advance Beneficiary Notice of Noncoverage (ABN), also known as CMS Form R-131, is a standardized form that Medicare-participating providers and suppliers must give you when they believe Medicare will not pay for a specific service or item.
The ABN must be given before the service is provided, giving you time to make an informed decision. It is not a bill - it is a notice that explains why Medicare may not pay and what your options are.
What It Covers
- Notifies you before a potentially non-covered service
- Explains the specific reason Medicare may deny payment
- Gives you options to accept or decline the service
- Preserves your right to appeal Medicare's decision
What It Doesn't Cover
- Does not apply to services Medicare never covers (like cosmetic surgery)
- Does not apply to Medicare Advantage plans (they use NEMB form)
- Not required for emergency services
- Not a guarantee that Medicare will deny the claim
If you choose to receive the service and Medicare denies it, you are responsible for the full cost. If you don't receive an ABN and Medicare denies the claim, the provider cannot bill you.
When Providers Must Issue an ABN
Providers must give you an ABN when they have reason to believe Medicare will not pay for a service that would normally be covered. Common situations include: services exceeding frequency limits, items not meeting medical necessity criteria, or services provided by non-participating suppliers.
The ABN must be delivered far enough in advance for you to make an informed decision. It cannot be given after the service has already been provided.
What It Covers
- Services exceeding Medicare frequency limits
- Items that may not meet medical necessity criteria
- Lab tests that may not be covered for your diagnosis
- DME that may not be approved
- Services from non-participating providers
What It Doesn't Cover
- Services Medicare categorically excludes (cosmetic, custodial)
- Emergency or urgently needed services
- Services already denied by Medicare (too late for ABN)
Important Protection
If a provider fails to give you an ABN before a service Medicare denies, the provider cannot hold you financially responsible. You are only liable if you signed an ABN acknowledging the risk.
Your 3 Options on an ABN
When you receive an ABN, you must choose one of three options by checking a box on the form. Each option has different financial and appeal implications.
What It Covers
- Option 1: Get the service, have Medicare billed, and accept responsibility if denied (preserves appeal rights)
- Option 2: Get the service but pay out-of-pocket without billing Medicare (no appeal rights)
- Option 3: Decline the service entirely (no cost, no appeal needed)
What It Doesn't Cover
- You cannot choose more than one option
- Leaving the form blank defaults to Option 1
- You cannot change your choice after the service is provided
ABN Options and Financial Impact
| Option | Service Received? | Medicare Billed? | You Pay If Denied? | Appeal Rights? |
|---|---|---|---|---|
| Option 1 | Yes | Yes | Yes - full cost | Yes |
| Option 2 | Yes | No | Yes - full cost | No |
| Option 3 | No | No | No cost | N/A |
✦ When an ABN is not Required
Categorically Excluded Services
Providers do not need to issue an ABN for services Medicare never covers under any circumstance, such as cosmetic surgery, routine dental care, or hearing aids under Original Medicare. These are considered 'categorically excluded' and a different notice (the NEMB for MA plans or no notice for Original Medicare) applies.
If you receive a service Medicare never covers and weren't given an ABN, you are still responsible for payment because ABNs only apply to services Medicare sometimes covers.
✦ ABN Regulatory Updates
Revised ABN Form (CMS-R-131)
PassedCMS periodically updates the ABN form. Providers must use the current version. The most recent revision clarified language around patient options and added accessibility requirements.
Electronic ABN Delivery
PassedCMS now allows electronic delivery of ABNs with proper patient consent, making it easier for telehealth providers to comply with notification requirements.
What to do When You Receive an ABN
Follow these steps when a provider hands you an Advance Beneficiary Notice to protect your rights and finances.
ABN Action Steps
- Read the ABN carefully - understand which specific service may not be covered and why
- Ask your provider to explain the reason Medicare might deny the claim
- Consider choosing Option 1 if you believe the service should be covered - this preserves your appeal rights
- Ask for a cost estimate so you know your potential financial responsibility
- Keep a copy of the signed ABN for your records
- If Medicare denies the claim, file an appeal within 120 days using the instructions on your Medicare Summary Notice
✦ Frequently Asked Questions
David Haass
AuthorLicensed Medicare agent specializing in Medicare benefits and coverage guidance.
Lindsay Malzone
ReviewerMedicare expert and compliance reviewer with over 10 years of experience.