CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions

Form Instructions
Advance Beneficiary Notice of Non-coverage (ABN)
OMB Approval Number: 0938-0566
Overview
The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is
not likely to provide coverage in a specific case. “Notifiers” include:
•

Physicians, providers (including institutional providers like outpatient hospitals),
practitioners and suppliers paid under Part B (including independent laboratories);

•

Hospice providers and religious non-medical health care institutions (RNHCIs) paid
exclusively under Part A; and

•

Home health agencies (HHAs) providing care under Part A or Part B.

All of the aforementioned healthcare providers and suppliers must complete the ABN as
described below in order to transfer potential financial liability to the beneficiary, and deliver
the notice prior to providing the items or services that are the subject of the notice.
Medicare inpatient hospitals and skilled nursing facilities (SNFs) use other approved notices
for Part A items and services when notice is required in order to shift potential financial
liability to the beneficiary; however, these facilities must use the ABN for Part B items and
services.
The ABN must be reviewed with the beneficiary or his/her representative and any questions
raised during that review must be answered before it is signed. The ABN must be delivered
far enough in advance that the beneficiary or representative has time to consider the options
and make an informed choice. Employees or subcontractors of the notifier may deliver the
ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are
completed and the form is signed, a copy is given to the beneficiary or representative. In all
cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file.
The ABN may also be used to provide notification of financial liability for items or services
that Medicare never covers. When the ABN is used in this way, it is not necessary for the
beneficiary to choose an option box or sign the notice.
ABN Changes
The ABN is a formal information collection subject to approval by the Executive Office of
Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA). As part
of this process, the notice is subject to public comment and re-approval every 3 years. With
the latest PRA submission, a change has been made to the ABN. In accordance with Title 18
of the Social Security Act, guidelines for Dual Eligible beneficiaries have been added to the
ABN form instructions.

Completing the Notice
ABNs may be downloaded from the CMS website
at: http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html .
Instructions for completion of the form are set forth below:
ABNs must be reproduced on a single page. The page may be either letter or legal-size, with
additional space allowed for each blank needing completion when a legal-size page is used.
There are 10 blanks for completion in this notice, labeled from (A) through (J). We
recommend that notifiers remove the lettering labels from the blanks before issuing the ABN
to beneficiaries. Blanks (A)-(F) and blank (H) may be completed prior to delivering the
notice, as appropriate. Entries in the blanks may be typed or hand-written, but should be
large enough (i.e., approximately 12-point font) to allow ease in reading. (Note that 10 point
font can be used in blanks when detailed information must be given and is otherwise difficult
to fit in the allowed space.) The notifier must also insert the blank (D) header information
into all of the blanks labeled (D) within the Option Box section, Blank (G). One of the check
boxes in the Option Box section, Blank (G), must be selected by the beneficiary or his/her
representative. Blank (I) should be a cursive signature, with printed annotation if needed in
order to be understood.
Header:
Blanks A-C, the header of the notice, must be completed by the notifier prior to delivering
the ABN.
1. Blank (A) Notifier(s): Notifiers must place their name, address, and telephone
number (including TTY number when needed) at the top of the notice. This
information may be incorporated into a notifier’s logo at the top of the notice by
typing, hand-writing, pre- printing, using a label or other means.
If the billing and notifying entities are not the same, the name of more than one entity
may be given in the Header as long as it is specified in the Additional Information
(H) section who should be contacted for billing questions.
2. Blank (B) Patient Name: Notifiers must enter the first and last name of the
beneficiary receiving the notice, and a middle initial should also be used if there is
one on the beneficiary’s Medicare card. The ABN will not be invalidated by a
misspelling or missing initial, as long as the beneficiary or representative recognizes
the name listed on the notice as that of the beneficiary.
3. Blank (C) Identification Number: Use of this field is optional. Notifiers may enter
an identification number for the beneficiary that helps to link the notice with a related
claim. The absence of an identification number does not invalidate the ABN. An
internal filing number created by the notifier, such as a medical record number, may

be used. Medicare numbers (HICNs), Medicare beneficiary identifiers (MBIs), or
Social Security numbers should not appear on the notice.
Body:
4. Blank (D): The following descriptors may be used in the Blank (D) fields:
Item
Service
Laboratory test
Test
Procedure
Care
Equipment
•
•
•
•

•

•

The notifier must list the specific names of the items or services believed to be
non-covered in the column directly under the header of Blank (D).
In the case of partial denials, notifiers must list in the column under Blank (D)
the excess component(s) of the item or service for which denial is expected.
For repetitive or continuous non-covered care, notifiers must specify the
frequency and/or duration of the item or service.
General descriptions of specifically grouped supplies are permitted in this
column. For example, “wound care supplies” would be a sufficient
description of a group of items used to provide this care. An itemized list
of each supply is generally not required.
When a reduction in service occurs, notifiers must provide enough additional
information so that the beneficiary understands the nature of the reduction.
For example, entering “wound care supplies decreased from weekly to
monthly” would be appropriate to describe a decrease in frequency for this
category of supplies; just writing “wound care supplies decreased” is
insufficient.
Please note that there are a total of 7 Blank (D) fields that the notifier must
complete on the ABN. Notifiers are encouraged to populate all of the Blank
(D) fields in advance when a general descriptor such as “Item(s)/Service(s)” is
used. All Blank (D) fields must be completed on the ABN in order for the
notice to be considered valid.

5. Blank (E) Reason Medicare May Not Pay: In the column under this header,
notifiers must explain, in beneficiary friendly language, why they believe the items or
services listed in the column under Blank (D) may not be covered by Medicare.
Three commonly used reasons for non-coverage are:
“Medicare does not pay for this test for your condition.”
“Medicare does not pay for this test as often as this (denied as too frequent).”
“Medicare does not pay for experimental or research use tests.”

To be a valid ABN, there must be at least one reason applicable to each item or
service listed in the column under Blank (D). The same reason for non-coverage may
be applied to multiple items in Blank (D) when appropriate.
6. Blank (F) Estimated Cost: Notifiers must complete the column under Blank (F) to
ensure the beneficiary has all available information to make an informed decision
about whether or not to obtain potentially non-covered services.
Notifiers must make a good faith effort to insert a reasonable estimate for all of the
items or services listed under Blank (D). In general, we would expect that the
estimate should be within $100 or 25% of the actual costs, whichever is greater;
however, an estimate that exceeds the actual cost substantially would generally still
be acceptable, since the beneficiary would not be harmed if the actual costs were less
than predicted.
Multiple items or services that are routinely grouped can be bundled into a single cost
estimate. For example, a single cost estimate can be given for a group of laboratory
tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also
permissible for long term or complex projections. As noted above, providers may
also pre-print a menu of items or services in the column under Blank (D) and include
a cost estimate alongside each item or service. If a situation involves the possibility
of additional tests or procedures (such as in laboratory reflex testing), and the costs
associated with such tests cannot be reasonably estimated by the notifier at the time
of ABN delivery, the notifier may enter the initial cost estimate and indicate the
possibility of further testing. Finally, if for some reason the notifier is unable to
provide a good faith estimate of projected costs at the time of ABN delivery, the
notifier may indicate in the cost estimate area that no cost estimate is available. We
would not expect either of these last two scenarios to be routine or frequent practices,
but the beneficiary would have the option of signing the ABN and accepting liability
in these situations.
7. Blank (G) Options: Blank (G) contains the following three options:
•

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. If Medicare does pay, you will refund any payments I made to you, less
co-pays or deductibles.
This option allows the beneficiary to receive the items and/or services at issue and
requires the notifier to submit a claim to Medicare. This will result in a payment
decision that can be appealed.

Suppliers and providers who don’t accept Medicare assignment may make
modifications to Option 1 only as specified below under “H. Additional
Information.”
* 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:
Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN
in order for a claim to be submitted for Medicare adjudication.
Strike through Option Box 1 as provided below:
□ 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.
These edits are required because the provider cannot bill the dual eligible beneficiary
when the ABN is furnished. Providers must refrain from billing the beneficiary
pending adjudication by both Medicare and Medicaid in light of federal law affecting
coverage and billing of dual eligible beneficiaries. If Medicare denies a claim where
an ABN was needed in order to transfer financial liability to the beneficiary, the
claim may be crossed over to Medicaid or submitted by the provider for adjudication
based on State Medicaid coverage and payment policy. Medicaid will issue a
Remittance Advice based on this determination.
Once the claim is adjudicated by both Medicare and Medicaid, providers may only
charge the patient in the following circumstances:
•

If the beneficiary has QMB coverage without full Medicaid coverage, the ABN
could allow the provider to shift financial liability to the beneficiary per Medicare
policy.

•

If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or
will not pay because the provider does not participate in Medicaid), the ABN
could allow the provider to shift financial liability to the beneficiary per Medicare
policy, subject to any state laws that limit beneficiary liability.

Note: These instructions should only be used when the ABN is used to transfer
potential financial liability to the beneficiary and not in voluntary instances. More
information on dual eligible beneficiaries may be found
at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glan
ce.pdf

•

OPTION 2. I want the (D)
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.
This option allows the beneficiary to receive the non-covered items and/or services
and pay for them out of pocket. No claim will be filed and Medicare will not be
billed. Thus, there are no appeal rights associated with this option.

•

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.
This option means the beneficiary does not want the care in question. By checking
this box, the beneficiary understands that no additional care will be provided; thus,
there are no appeal rights associated with this option.

The beneficiary or his or her representative must choose only one of the three options
listed in Blank (G). Unless otherwise instructed to do so according to the specific
guidance provided in these instructions, the notifier must not decide for the beneficiary
which of the 3 checkboxes to select. Pre-selection of an option by the notifier invalidates
the notice. However, at the beneficiary’s request, notifiers may enter the beneficiary’s
selection if he or she is physically unable to do so. In such cases, notifiers must annotate
the notice accordingly.
If there are multiple items or services listed in Blank (D) and the beneficiary wants to
receive some, but not all of the items or services, the notifier can accommodate this
request by using more than one ABN. The notifier can furnish an additional ABN listing
the items/services the beneficiary wishes to receive with the corresponding option.
If the beneficiary cannot or will not make a choice, the notice should be annotated, for
example: “beneficiary refused to choose an option.”
8. Blank (H) Additional Information: Notifiers may use this space to provide
additional clarification that they believe will be of use to beneficiaries. For example,
notifiers may use this space to include:
•
•
•
•

A statement advising the beneficiary to notify his or her provider about certain
tests that were ordered, but not received;
Information on other insurance coverage for beneficiaries, such as a Medigap
policy, if applicable;
An additional dated witness signature; or
Other necessary annotations.

Annotations will be assumed to have been made on the same date as that appearing in
Blank J, accompanying the signature. If annotations are made on different dates,
those dates should be 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 will refund any payments I made to you, less copays or deductibles.
This single line strike can be included on ABNs printed specifically for issuance
when unassigned items and services are furnished. Alternatively, the line can be
hand-penned on an already printed ABN. The sentence must be stricken and can’t be
entirely concealed or deleted. There is no CMS requirement for suppliers or the
beneficiary to place initials next to the stricken sentence or date the annotations when
the notifier makes the changes to the ABN before issuing the notice to the
beneficiary.
When this sentence is stricken, the supplier should include the following CMSapproved unassigned claim statement in the (H) 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 am 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.”
This statement can be included on ABNs printed for unassigned items and services,
or it can be handwritten in a legible 10 point or larger font.
An ABN with the Option 1 sentence stricken must contain the CMS-approved
unassigned claim statement as written above to be considered valid notice. Similarly,
when the unassigned claim statement is included in the “Additional Information”
section, the last sentence in Option 1 should be stricken.
Signature Box:
Once the beneficiary reviews and understands the information contained in the ABN, the
Signature Box is to be completed by the beneficiary (or representative). This box cannot be
completed in advance of the rest of the notice.
9. Blank (I) Signature: The beneficiary (or representative) must sign the notice to
indicate that he or she has received the notice and understands its contents. If a
representative signs on behalf of a beneficiary, he or she should write out
“representative” in parentheses after his or her signature. The representative’s name
should be clearly legible or noted in print.
10. Blank (J) Date: The beneficiary (or representative) must write the date he or she
signed the ABN. If the beneficiary has physical difficulty with writing and requests
assistance in completing this blank, the date may be inserted by the notifier.

Disclosure Statement: The disclosure statements in the footer of the notice are required to
be included on the document.
CMS will work with its contractors to ensure consistency when determining validity of the
ABN in general. In addition, contractors will provide ongoing education to notifiers as
needed to ensure proper notice delivery. Notifiers should contact the appropriate CMS
regional office if they believe that a contractor inappropriately invalidated an ABN.