Advance Beneficiary Notice: when a Medicare provider can bill you
For a service Medicare usually covers, a provider can generally bill you after a Medicare denial only if it gave you a valid Advance Beneficiary Notice (Form CMS-R-131, with 3 options to choose from) before the service and you agreed to pay. Without a proper ABN where one was required, CMS instructions relieve you of liability. With one, you may owe the provider's usual fee, which can exceed the Medicare fee schedule amount. Services Medicare never covers by law, such as routine eye care or dental care, are different: an ABN is optional and you may owe regardless.
The ABN is the one piece of paper in Original Medicare that moves financial risk from the provider to you, in a single signature. It is also one of the least explained. Patients are handed it at a desk, often alongside other forms, with a few handwritten lines and three boxes to choose from. This guide explains what the form is for, when a provider is required to use it, what makes it valid or invalid, what each of the three options means for your rights, and how to work out, after a denial, whether the provider can bill you.
The rules come from the Medicare Claims Processing Manual, chapter 30, section 50, which governs the ABN (Form CMS-R-131), and from CMS training material on completing the form, both checked on October 22, 2026. This is information about billing rules, not legal advice, and it covers Original Medicare only. The cost-sharing arithmetic for a covered service is a separate topic, covered in what Medicare patients pay for an outpatient procedure.
What the ABN is, and what it is not
The legal basis is the limitation on liability provision in section 1879 of the Social Security Act. CMS instructions describe it this way: a healthcare provider or supplier must notify a beneficiary in advance of furnishing an item or service when it believes the item or service will likely be denied by Medicare for certain reasons, in order to shift financial liability to the beneficiary if Medicare denies the claim. The notice is the way the provider establishes that you knew in advance that Medicare might not pay. The manual's own example is a service that may be denied as not reasonable and necessary, or that is custodial care.
The ABN is not a denial. It is a prediction by the provider that Medicare may deny. Medicare has not decided anything yet when you sign. Whether Medicare pays depends on the claim, the record and Medicare's coverage rules, and the ABN does not alter any of those. The ABN is also not a bill and it is not a price quote in the sense of a guaranteed amount. It carries an estimate of cost, and it carries the provider's reason for expecting denial, and it lets you choose what happens next.
Three limits are stated in the manual and they come up often:
- Original Medicare only. The ABN is given to beneficiaries enrolled in the Medicare fee-for-service program. It is not used for items or services under Medicare Advantage or for prescription drugs under Part D.
- Part B services in general. The form is issued by providers and suppliers of Part B items and services, with a few specific Part A uses for hospice, religious nonmedical health care institutions and home health agencies. A skilled nursing facility uses a different form, the SNF ABN (CMS-10055), for Part A stays.
- Only enrolled providers. With the exception of durable medical equipment suppliers, only providers and suppliers enrolled in Medicare can issue it.
When a provider must give one, when it may, and when it may not
The manual draws three lines. Reading them in order answers most "why was I handed this" questions.
| Situation | Is an ABN required? | Manual reference |
|---|---|---|
| The service is usually covered, but Medicare is expected to deny it in this case as not reasonable and necessary (for example, a test at a frequency or for a reason Medicare does not pay) | Yes, to shift liability to you | Section 50, 50.2 |
| Custodial care | Yes, to shift liability | 50.2 |
| An experimental or "research use only" test that Medicare treats as not reasonable and necessary | Yes, to shift liability | 50.2 |
| Certain durable medical equipment denials (unsolicited telephone contact, supplier number requirements, denials in advance) | Yes, in the listed cases | 50.2, 50.10 to 50.13 |
| Care that Medicare never covers by law, such as routine eye care, dental care, routine foot care or personal comfort items | No. Optional, as a courtesy; you are not asked to choose an option or sign | 50.2.1 |
| A medical emergency, or a patient under similar duress | Generally may not be issued; forced delivery may be considered coercive | 50.17 C |
| A service paid in full through a bundled payment where you would not otherwise owe | Cannot be used to shift liability | 50.9 A |
| Medicare Advantage or Part D drug | Not used | 50.1 |
Source: Medicare Claims Processing Manual, chapter 30, section 50 (sections as listed), checked October 22, 2026.
Two details deserve a longer look. First, the optional use. A provider that hands you an ABN for something Medicare never covers, for example routine eye care or dental care, is not shifting liability, because you already owed those costs. The manual says a form used this way is a courtesy to forewarn you, and that you should not be asked to choose an option or sign. If you are being asked to sign an option box for a service on the never-covered list, ask what the signature is for. The rules for the covered services this site prices, like the cataract surgery price page, can differ from the eyeglass and routine eye exam rules that follow it.
Second, the emergency line. The manual says in general a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress. Use of an ABN in an emergency room may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues. For ambulance transports, the manual sets out three conditions that must all be met before an ABN is mandatory: the service is a covered ambulance benefit, the provider believes it may be denied as not reasonable and necessary on that occasion, and the transport is non-emergency, with the patient not under duress.
Reading the form: what each part must tell you
The ABN is a one-page form with lettered blanks. CMS training material walks through them. The letters are removed from the version you receive, but the content is the same. Here is what each part has to contain and what to check.
| Part of the form | What the provider must fill in | What to check |
|---|---|---|
| Notifier | Name, address and phone of the provider or supplier; if a different entity bills, its contact details somewhere on the form | You know who will bill you and whom to call |
| The item or service | A description in language you understand, one line per item, with frequency or duration for repeated care | It names the specific service, not "any service Medicare may not cover" |
| Reason Medicare may not pay | A genuine reason for each item, such as that Medicare does not pay for the test for your condition, or at this frequency, or because it is experimental | Every listed item has a reason that applies to it |
| Estimated cost | A good-faith effort to give a reasonable estimate for the items or services listed; routinely grouped items can share one estimate | An estimate is given, or the form says no estimate is available; a generous estimate is allowed, so ask what it is based on |
| Options | Three boxes for you to choose from; the provider may not choose for you | You decide, and you understand the difference between Options 1 and 2 |
| Additional information | Anything that clarifies, such as who bills if it is another entity | Questions you asked and answers you were given can be noted here |
| Signature and date | You, or your representative, sign and date | The blanks above were filled in before you signed |
On the estimate: the current CMS ABN form instructions say a notifier must make a good-faith effort to insert a reasonable estimate for all of the items or services listed, and that an estimate that substantially exceeds the actual cost would generally still be acceptable, since the patient would not be harmed if actual costs were less. Routinely grouped items, such as a panel of laboratory tests, can share a single estimate, and an average daily estimate is permitted for long-term or complex projections. Where the possibility of further testing means costs cannot reasonably be estimated, the notifier may enter an initial estimate and note that more may follow, and if it cannot estimate at all it may indicate that no cost estimate is available. CMS says it does not expect either of those last two to be routine, and the patient still has the option of signing and accepting liability. An older CMS training tutorial from 2015 gave $100 or 25 percent of the actual cost, whichever is greater, as what Medicare generally expects; it is dated, so treat it as background rather than the current test. The practical questions are what the estimate is based on, and whether a very high or missing estimate leaves you unable to judge the risk.
The manual also lists what does not count. "Generic" notices that only state that Medicare denial of payment is possible, or that the provider never knows whether Medicare will pay, are not acceptable evidence of notice. "Blanket" notices, given for all claims or all items regardless of the individual case, are not acceptable; notice must rest on a genuine judgment about the likelihood of payment for that patient's claim. And a provider may not get your signature on a blank form and fill it in later; a notice that was blank when signed is invalid. If the form handed to you is blank, or says only "any services," you are looking at a defective notice.
The three options, and what each one does to your rights
This is the part of the ABN that people most often sign without reading, and it has the largest consequences. The wording below is summarized from the form and CMS training material.
| Option | What you are saying | Is Medicare billed? | Can you appeal? |
|---|---|---|---|
| Option 1 | I want the service. The provider may ask me to pay now, but I also want Medicare billed for an official decision. If Medicare does not pay, I am responsible. | Yes. A payment decision is sent to you on a Medicare Summary Notice | Yes, by following the directions on the Medicare Summary Notice |
| Option 2 | I want the service and I accept financial responsibility. I agree to pay now if required. Do not bill Medicare. | No claim is filed at your request | No appeal rights, because no claim exists |
| Option 3 | I do not want the service. I understand I am not responsible for payment. | No claim, no service | No appeal rights |
Source: Medicare Claims Processing Manual chapter 30, 50.17 (Option 1 wording and claims submission); CMS ABN interactive tutorial text, ICN 909183, July 2015 (option descriptions). Checked October 22, 2026.
The central trade is between Option 1 and Option 2. Option 1 keeps your rights alive: Medicare gets the claim and makes a decision, you receive a Medicare Summary Notice, and if you disagree you can appeal. You may be asked to pay up front, but if Medicare pays or if an appeal succeeds, you can get money back. Option 2 gives those rights up, because no claim is filed, so you can never find out whether Medicare would have paid. The manual notes that a provider does not violate the mandatory claim submission rules when it does not submit a claim at your written request under Option 2. If a supplemental insurer needs a Medicare denial before it will pay its share, CMS training material says the provider may advise you to select Option 1.
The provider may not choose the box. Training material says the beneficiary or representative must choose one of the three options, and that Medicare does not permit the provider to make the selection. The manual adds that after you sign, you may change your mind: the provider presents the form again and you annotate it with the new choice, your signature and the date, and any related claim is revised or cancelled to match.
You always keep one right. The manual says that upon receipt of an ABN, beneficiaries always have the right to ask the provider to submit a claim to Medicare for an official payment decision, and that to request this you must receive the service described and choose Option 1.
What a valid ABN looks like in practice
The manual sets out the elements of effective delivery. If any is missing, the notice is defective, and the provider may not use it to shift liability. Because the burden of proof is on the provider, the checklist is worth reading as a patient.
- The current, approved form. It must be the standard OMB-approved ABN, Form CMS-R-131, with all required blanks completed. A homemade waiver is not an ABN.
- In person, if possible. When in-person delivery is not possible, the manual allows delivery by telephone followed by mailed, emailed or faxed notice, by mail, by secure fax or by email, with a response from you to validate delivery.
- Far enough in advance. It must be given before the potentially non-covered service, with enough time for you to consider your options.
- Explained in full, and your questions answered. The provider is supposed to explain the notice completely and answer your related questions accurately and completely. If you have questions it cannot answer, the manual says the provider should direct you to 1-800-MEDICARE, and that a contractor finding the provider refused to answer your questions or to direct you there will consider the delivery defective.
- Signed by you or your representative after the form is completed.
- A copy for you. The manual says a minimum of two copies should be made so you and the provider each have one, and that even if it is signed electronically you should be given a paper copy to keep, if you prefer it.
A notice delivered while you are on a gurney, in pain, or minutes before a procedure begins is open to challenge on the timing and duress points. This guide does not decide those cases. Medicare contractors do, usually when they review an ABN-related claim.
How long an ABN lasts, and what it cannot do
For repeated or continuing care, the manual says an ABN remains effective after valid delivery so long as there is no change in the care from what is described on the original notice, in your health status in a way that requires a change in treatment, or in the Medicare coverage guidelines for the services. If any of those changes, a new ABN must be issued. For repetitive or continuous noncovered care, the provider may issue another ABN after one year, but is not required to unless one of the changes occurs. A single ABN can cover an extended course of care if it lists every item and service the provider believes Medicare will not cover and states the duration.
One rule protects you in particular. If the provider failed to issue an ABN before the first episodes of repetitive care, it can issue one at any point during the course of treatment, but the manual says it cannot be retroactively dated or used to shift liability for care already provided. Care furnished before the ABN is delivered remains the provider's financial responsibility. The same logic applies in general: an ABN handed over after a service, or with a backdated signature, does not shift liability for that service.
After a denial: can they bill me? A working order of questions
Take the Medicare Summary Notice for the claim, the bill from the provider, and any ABN you signed. Then work through these in order.
- Was it Original Medicare? If you have a Medicare Advantage plan, the ABN rules in this guide do not apply, and your plan's notice and appeal rules do.
- Did Medicare deny the service? A bill from the provider without a Medicare denial on the Medicare Summary Notice is not an ABN question. Ask whether the claim was submitted and processed.
- What was the reason for the denial? The manual's liability rules apply to denials such as not reasonable and necessary. A denial for a service that Medicare never covers by law is a statutory exclusion, where an ABN was optional and you may owe regardless.
- Was there a valid ABN before the service? Use the validity checklist above: right form, filled in before signing, specific item and reason, estimate, you chose the option, advance timing, and a copy.
- Which option did you choose? With Option 1, the Medicare denial and your appeal rights are the next step. With Option 2, you agreed to pay and no claim exists.
- Does the charge match the estimate? The manual says the amount a beneficiary can be charged may be the provider's usual and customary fee, not limited to the Medicare fee schedule. If the bill is far above the estimate on the form, ask the provider to explain the difference, and keep the estimate on the form as your record.
- If no valid ABN was required and given, what did the provider collect? The manual says a provider that fails to issue a required ABN, or issues a defective one, is generally precluded from collecting from the beneficiary and must make prompt refunds of funds collected.
If the answers point to a billing error, ask the provider's billing office for a written explanation first, then follow the directions on the Medicare Summary Notice to appeal, or call 1-800-MEDICARE. For a general routine on organizing an argument with a billing office, the itemized bill check and the hospital bill negotiation guide give the order in which to ask.
A worked scenario, with invented numbers
Suppose a clinic tells a Medicare patient that a particular test is likely to be denied at the frequency ordered, and hands over an ABN that names the test, gives the reason "Medicare does not pay for this test at this frequency," estimates $240, and offers the three options. The numbers below are hypothetical and chosen only to show how the rules fit together.
| What happens (hypothetical) | Result |
|---|---|
| Patient chooses Option 1, signs. The clinic bills Medicare. Medicare denies as not reasonable and necessary at that frequency. | The patient received a Medicare Summary Notice with the denial and appeal directions. The provider may bill the patient. The charge may be the clinic's usual fee, here $260, not a Medicare fee schedule figure. The patient can appeal the denial. |
| Patient chooses Option 2, signs. No claim is filed. | The patient pays the clinic. No Medicare Summary Notice, no appeal, and no way to learn whether Medicare would have paid. |
| Patient chooses Option 3. | No test, no claim, no charge. |
| The clinic gave no ABN, and Medicare denies the claim for the same reason. | If an ABN was required, the manual relieves the patient of liability. The clinic is generally barred from collecting from the patient and must refund any payment already taken. |
| The clinic gave a blank form for signature and filled it in afterward. | A notice that was blank when signed is invalid, so the patient is treated as having received no notice. |
The estimate in the first row was $240 and the charge $260. That is within the $100-or-25-percent training guidance, so there is nothing to dispute about the estimate itself. If the charge were $600, the difference would be worth a question. The provider could be right that the service cost more than expected, but the written estimate is the starting point of the conversation.
Special situations
Medicare and Medicaid together
For beneficiaries who are dually eligible, including those with Qualified Medicare Beneficiary coverage, the manual instructs the provider to strike through the Option 1 wording that says the provider may ask for payment now, and to have the patient check Option 1 so a claim is submitted. The provider must refrain from billing the patient while Medicare and Medicaid adjudicate. Afterward, a provider can charge the patient only in limited cases: where the patient has QMB coverage without full Medicaid coverage, the ABN could allow liability to shift per Medicare policy, and where the patient has full Medicaid and Medicaid denies the claim or does not pay because the provider does not participate, liability could shift subject to state law limits. If you have both, ask the provider how it will handle the notice before you sign.
You refuse to choose or sign
The manual says the provider should annotate the form to note the refusal, may list witnesses, and should give you a copy. It adds that the provider should consider not furnishing the item or service unless the consequences for your health or safety, or civil liability in case of harm, are such that this is not an option. Declining to sign is allowed. It may mean the provider will not do the service.
A representative signs for you
If you have a known, legally authorized representative, the ABN must be issued to that representative. The representative should write "representative" next to the signature and print the name if it is not legible.
Another entity does the billing
A physician's office that sends a specimen to a laboratory, or an imaging facility and a physician who reads the scan, may use one ABN. The manual says either party can be the notifier, and the form should say how to reach the billing entity.
Ambulance
For a non-emergency transport the manual sets the three conditions given earlier, and notes that an ABN is mandatory only when a covered ambulance transport is modified to a level that is not medically reasonable and necessary and will cost more. The broader gap in federal protections for ground ambulance bills is the subject of its own guide, ground ambulance bills and the federal gap.
Questions to ask before you sign
- Which exact service, and why does the provider expect Medicare to deny it for me?
- What is the estimate based on, and is it the provider's usual fee or a Medicare amount?
- If I choose Option 1, will you ask me to pay now, and will you refund me if Medicare pays?
- Is there a covered alternative at a different frequency or in a different setting that Medicare would pay for? (This is a billing question, not a medical one; your clinician decides what care you need.)
- Will you give me a copy of the signed form?
- Who bills, and who do I call with questions after the service?
If the answers do not satisfy you, 1-800-MEDICARE is the number the manual says the provider is supposed to direct you to for unanswered questions.
What an ABN does not change
It does not change Medicare's coverage rules. It does not change the Medicare-approved amount for any service that Medicare does pay for. It does not take away your right to a Medicare Summary Notice and an appeal under Option 1. It does not apply to an item the provider never expected Medicare to deny. And an ABN is a prediction, not a decision: Medicare's own claim decision is what determines whether the service is paid.
Before you sign: frequent questions
What is an Advance Beneficiary Notice of Noncoverage?
It is Form CMS-R-131, a written notice that a provider or supplier gives an Original Medicare patient before furnishing an item or service that Medicare usually covers but is expected to deny in this particular case, most often because it is not considered reasonable and necessary. It exists so the patient can decide, with a cost estimate in hand, whether to receive the service and accept financial responsibility.
If I sign an ABN, do I have to pay?
Not automatically. CMS instructions say a beneficiary who has been given a properly delivered ABN and agrees to pay may be held liable, but only if Medicare actually denies payment. Choosing Option 1 asks the provider to bill Medicare first, and Medicare's decision then determines what you owe. Choosing Option 2 means no claim is filed and no appeal is possible.
What if I was never given an ABN and Medicare denied the claim?
The Medicare manual says that if the beneficiary does not receive proper notice when one is required, the beneficiary is relieved of liability, and the provider is generally prevented from collecting from the patient and must refund any money already collected. Whether an ABN was required in your case is a question for the Medicare contractor to decide, so keep the bill and the Medicare Summary Notice together.
Can a provider make me sign an ABN in an emergency?
The manual says that, in general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress, and that forcing delivery of an ABN during an emergency may be considered coercive. It adds that ABN use in an emergency room may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.
Does an ABN apply if I have a Medicare Advantage plan?
No. The manual states that the ABN is not used for items or services under the Medicare Advantage program or for prescription drugs under Part D. A Medicare Advantage plan uses its own organization determinations and notices.
Is the ABN price a cap on what I can be charged?
The estimate is part of the notice, and the current CMS form instructions require a good-faith effort at a reasonable estimate, with allowances for grouped items and, rarely, for no estimate being available. The manual also says that the amount a beneficiary can be charged after a valid ABN may be the provider's usual and customary fee, not limited to the Medicare fee schedule. A 2015 CMS training tutorial used $100 or 25 percent of the actual cost, whichever is greater; it is dated, and the current instructions also say an estimate that substantially exceeds the actual cost would generally still be acceptable.
Where the rules come from
- CMS, Medicare Claims Processing Manual, chapter 30, Financial Liability Protections, section 50 (ABN scope, uses, optional uses, issuance, standards, effective delivery, effects of lack of notice, special considerations, and the rules against generic, blanket and signed-blank notices). Checked October 22, 2026.
- CMS, Form Instructions for the Advance Beneficiary Notice of Noncoverage (ABN), estimated cost section. Checked October 22, 2026.
- CMS Medicare Learning Network, Advance Beneficiary Notice of Noncoverage Interactive Tutorial, text-only version (ICN 909183, July 2015), for the form fields, option wording and the estimate guidance. This is dated training material. Checked October 22, 2026.
- Medicare.gov, Costs, for Original Medicare cost sharing. Checked October 22, 2026.
General information about Medicare billing rules, not legal advice. The Medicare manual, your Medicare Summary Notice and the Medicare contractor control in a real case. Prices only on this site: no diagnosis or treatment advice. Confirm any price in writing before service.
If you are facing an ABN for a planned procedure, the most useful next step is to work out your normal Medicare share for that service, so you can compare it with the estimate on the form and see what the notice would add to your costs.