What Is an Advance Beneficiary Notice (ABN)?

You're sitting in a waiting room or about to undergo a procedure when a staff member slides a form across the desk and asks you to sign it. That form may be an Advance Beneficiary Notice — and signing it without understanding what it means could cost you hundreds or thousands of dollars. Knowing exactly what an ABN is, when it's required, and what your options are can mean the difference between a bill Medicare covers and one you're stuck paying out of pocket.

What is an Advance Beneficiary Notice of Noncoverage (ABN) and why does it exist?

An Advance Beneficiary Notice of Noncoverage, commonly called an ABN, is a standardized written notice that Medicare-participating providers are required to give you before delivering a service or item they expect Medicare will not cover or will deny as not medically necessary. The form is issued by the Centers for Medicare and Medicaid Services (CMS) and carries the official form number CMS-R-131. Its purpose is straightforward: to protect you from surprise bills by disclosing in advance that you — not Medicare — may end up responsible for the cost.

ABNs apply specifically to Original Medicare (Parts A and B) beneficiaries. They are used by physicians, outpatient hospitals, home health agencies, suppliers of durable medical equipment (DME), and other Medicare-enrolled providers. The ABN is not a denial of care — it is a financial disclosure tool. A provider can still deliver the service after you sign one, but they are now on record having told you the risk.

The legal basis for the ABN comes from the Medicare statute's "limitation on liability" provision (42 U.S.C. § 1395pp). Without a valid ABN on file, a provider generally cannot bill you if Medicare denies a claim. With a valid ABN, they can.

What must a valid ABN include to be legally enforceable?

Not every piece of paper a provider hands you qualifies as a legally valid ABN. CMS sets strict formatting and content requirements. A properly completed ABN must include all of the following:

• Your name and Medicare ID number
• The specific item or service in question — vague language like "tests" or "treatments" is not acceptable
• The reason(s) Medicare may not pay — for example, "Medicare does not usually pay for this many visits" or "Medicare does not pay for this service when it is done in an outpatient setting"
• An estimated cost of the item or service
• Three clearly labeled options (Option 1, Option 2, Option 3) for you to choose from
• Your signature and the date

The three options are critical. Option 1 means you want the service and want the provider to bill Medicare — even knowing it may be denied — so you can receive an official Medicare denial and potentially appeal. Option 2 means you want the service but do not want Medicare billed; you agree to pay out of pocket. Option 3 means you do not want the service. You must choose one and sign.

If a provider gives you a form that is missing the cost estimate, uses blanket or boilerplate language about unspecified services, or does not give you adequate time to read it before signing, the ABN may be considered defective and therefore unenforceable. You should not be pressured to sign immediately.

When are providers required to give you an ABN?

Providers must issue an ABN when they have a genuine, specific reason to believe Medicare will not cover a service — not simply as a routine administrative habit. CMS explicitly prohibits "blanket" ABNs issued to all patients for all services regardless of individual circumstances. Issuing an ABN as a matter of course, without a case-by-case reason, is considered an improper billing practice.

Common situations that legitimately trigger an ABN include:

• A service is considered not medically necessary under Medicare's Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs)
• You have already received the maximum number of covered visits for a service (e.g., physical therapy, home health)
• The service is being provided in a setting Medicare doesn't cover for that particular service
• A lab test or screening is being ordered more frequently than Medicare allows
• The item ordered is considered a convenience item rather than medically necessary equipment

Notably, ABNs are not required in emergency situations or when care cannot reasonably be delayed. They are also not used in Medicare Advantage (Part C) plans — those plans have their own notice requirements, including the Notice of Medicare Non-Coverage (NOMNC) for home health and skilled nursing facility services.

What are your rights when you receive an ABN?

Receiving an ABN does not mean you are powerless. You have several important rights under federal Medicare rules:

1. You have the right to time to review it. You should be given the form with enough time to read it carefully, ask questions, and consider your options. Handing you a form as you're being wheeled into a procedure room does not constitute adequate notice.
2. You have the right to choose Option 1 and have Medicare billed. This is often your best move. If Medicare pays, you owe nothing beyond normal cost-sharing. If Medicare denies the claim, you receive an official Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) — and that denial gives you the right to appeal.
3. You have the right to appeal a Medicare denial. The Medicare appeals process has five levels: Redetermination, Reconsideration by a Qualified Independent Contractor (QIC), Office of Medicare Hearings and Appeals (OMHA), Medicare Appeals Council, and Federal District Court. Many claims are overturned at the first or second level.
4. You have the right to refuse to sign. If you choose not to sign, the provider must note your refusal on the form. An unsigned ABN is generally treated the same as no ABN — meaning the provider takes on the financial liability risk if Medicare denies the claim.
5. You have the right to dispute an invalid ABN. If the form was defective, issued as a blanket notice, or presented improperly, you can challenge the provider's right to bill you. Document the circumstances and contact your State Health Insurance Assistance Program (SHIP) or a Medicare billing advocate.

How to dispute a bill you received after signing an ABN

Signing an ABN does not automatically mean you owe the full billed amount without recourse. Here are the steps to take if you believe a bill stemming from an ABN is incorrect or unfair:

1. Obtain the Medicare denial in writing. Request your Medicare Summary Notice (MSN) or ask the provider for the Explanation of Benefits showing the denial code and reason. The denial reason tells you exactly what basis Medicare used — and whether that basis is contestable.
2. Check the ABN for defects. Review the form you signed. Was a cost estimate included? Were specific services listed? Was a reason given? If any required element is missing, the ABN may be invalid and you may not legally owe the bill.
3. File a Medicare Redetermination request within 120 days. Submit CMS Form CMS-20027 or write a letter to the Medicare Administrative Contractor (MAC) that processed the claim. State clearly why you believe the service should be covered.
4. Request an itemized bill from the provider. Under federal law, you have the right to an itemized statement. Compare each line item to the services actually rendered. Billing errors frequently accompany coverage disputes.
5. Contact your SHIP counselor. State Health Insurance Assistance Programs provide free, unbiased help navigating Medicare billing disputes. Find your local SHIP at shiphelp.org.
6. Send a formal dispute letter to the provider. If the ABN was invalid, put your dispute in writing, cite the specific defect, and request that the provider write off the balance. Keep copies of everything.

What happens if a provider fails to give you an ABN when they should have?

This is one of the most misunderstood protections in Medicare billing. If a provider had reason to believe Medicare would deny a claim — and they failed to issue a proper ABN — they are generally prohibited from holding you financially responsible for that charge. This is the "limitation on liability" protection. In practical terms, it means:

• The provider cannot bill you for the denied amount
• If they have already billed you, you have grounds to demand a refund
• The provider may absorb the loss as a write-off, or they may appeal the Medicare denial themselves

If a provider insists on collecting payment they were not entitled to seek, you can file a complaint with your Medicare Administrative Contractor, your State Medical Board, or the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services. Improper ABN practices are a recognized form of Medicare fraud and abuse.