The Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, was implemented by the Centers for Medicare & Medicaid Services to inform Part B original beneficiaries when Medicare may deny payment for an item or service. The information below can help health care professionals understand the Medicare requirements for when and how to issue an ABN.
ABN Utilization
ABNs allow beneficiaries to make informed decisions about whether to get services and accept financial responsibility for services Medicare does not cover. The ABN serves as proof the beneficiary was informed prior to receiving a service Medicare may not pay. If a valid ABN is not issued to a beneficiary when Medicare requires it, the practice cannot bill the beneficiary for the service and you may be financially liable if Medicare doesn’t pay.
You may also use the ABN as an optional (voluntary) notice to alert beneficiaries of their financial liability prior to providing care that Medicare never covers. ABN issuance is not required to bill a beneficiary for an item or service that is not a Medicare benefit and never covered.
Mandatory ABN Uses
It is necessary to issue an ABN when:
- You expect Medicare to deny payment for an item or service
- Medicare considers the care to be custodial care
- Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception
See E/M Coding Guidelines >
Key Points for Health Care Providers
- You must issue an ABN to the beneficiary prior to providing care that Medicare may not cover.
- In situations where the ABN is required:
- Medicare permits you to bill the beneficiary after the beneficiary signs a valid ABN indicating his or her choice to get the item or service and accept financial liability, and
- If you do not issue an ABN or Medicare finds the ABN invalid, you may not bill the beneficiary for the services, and you may be financially liable if Medicare does not pay.
- You may not use ABNs to charge a beneficiary for a component of a service when Medicare makes full payment through a bundled payment.
- Medicare prohibits you from using an ABN to transfer liability to the beneficiary when Medicare would otherwise pay for items and services.
- When you issue the ABN as a voluntary notice, the beneficiary does not check an option box or sign and date the notice.
- The ABN is issued for items and services covered under Part B. It is only issued for Part A care provided by hospices, Home Health Agencies, and Religious Nonmedical Healthcare Institutions.
Common reasons for Medicare to deny an item or service as not medically reasonable and necessary include care that is:
- Experimental and investigational or considered “research only”
- Not indicated for diagnosis and/or treatment in this case
ABN Form - English
ABN Form - Spanish