ALWAYS choose Option 1 — this preserves your right to have Medicare billed and to appeal if denied

The ABN must explain WHY Medicare may not pay — vague reasons are not valid

You should NEVER be asked to sign a blank ABN or one that does not list specific items/services

Medicaremoderate

Advance Beneficiary Notice of Noncoverage (ABN)

CMS-R-131 · CMS

Notifies Original Medicare beneficiary before receiving a service that Medicare may not pay for. Patient decides whether to proceed and accept financial responsibility.

Form Details

Total fields: 15
Auto-fillable: 10 (67%)
Time without BeneFill: 10 minutes
Time with BeneFill: 3 minutes
Time saved: 7 minutes
Filled by: patient
Frequency: per incident

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Where to Submit This Form

🏢

Signed and returned to the provider before the service is performed

Your provider gives you this form before delivering a service they believe Medicare may not cover.

Required Attachments

📎 Your signature on the ABN (choose one of the options presented)
📎 No additional attachments required from the beneficiary

Processing Time

Immediate. The ABN must be signed before the service is provided.

What Happens Next

If you choose Option 1 (want the service and want Medicare billed), Medicare will make a coverage determination. If denied, you can appeal. If you choose Option 2, you agree to pay out of pocket. Option 3 means you decline the service.

Tips for This Form

✓ ALWAYS choose Option 1 — this preserves your right to have Medicare billed and to appeal if denied
✓ The ABN must explain WHY Medicare may not pay — vague reasons are not valid
✓ You should NEVER be asked to sign a blank ABN or one that does not list specific items/services
✓ If you receive an ABN after services are already provided, it may not be valid — you can dispute the charges

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