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 Original Medicare notice that a doctor's office, lab, imaging center or supplier uses to move financial risk from itself to you for a Part B item or service, with a single signature and a choice of three boxes. Hospitals and skilled nursing facilities have their own liability notices, set out in the table near the end. 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 28, 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:
- 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 shows which kind of case you are in.
| 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 28, 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.
The parts of the form, and what each 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
The option box is where the form's money consequences sit. 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 28, 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 whether it is issued on paper or on a screen, and however it is signed, you should be given a paper copy of the signed ABN to keep. You can also ask for a paper form instead of an electronic one.
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, when they review an ABN-related claim or investigate an allegation of improper notice (section 50.8 B).
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. Whatever its timing, an ABN also leaves Medicare's coverage rules and the Medicare-approved amount for any service Medicare pays unchanged: it is a prediction, and Medicare's claim decision is what determines payment.
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. A covered service billed by a doctor who does not accept assignment is a different case, where the ceiling is the limiting charge; the guide to Medicare excess charges explains it.
- 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 priced case: a bone density scan before its 24 months are up
A frequency limit is one of the reasons the manual names for expecting a denial, and a bone density scan shows the stakes with real Medicare figures. Medicare.gov says Medicare covers bone mass measurement once every 24 months, or more often if medically necessary, for people who meet certain conditions, and that you pay nothing for the test if the provider accepts assignment. CPT 77080 is the code for dual-energy X-ray absorptiometry (DXA) of the axial skeleton. Its 2026 Medicare anchors are below.
| Setting and payment system | Medicare anchor, CPT 77080 | Basis |
|---|---|---|
| Office or imaging center, PFS global (scan plus reading) | $38.75 | Michigan Locality 01, CY2026 |
| Professional component only (26), the reading | $9.50 | Michigan Locality 01, CY2026 |
| Hospital outpatient department, OPPS APC 5522 | $106.81 | National unadjusted, CY2026 |
| Your copayment when Medicare covers it, hospital outpatient | $0.00 | Addendum B national unadjusted copayment column |
Sources: CMS PFS relative value file RVU26D (October 2026 release) with the 2026 GPCIs for Michigan Locality 01 and the $33.4009 conversion factor; CMS OPPS October 2026 Addendum B. Recomputed and checked October 28, 2026. Medicare anchors are not your bill.
Now place two scans 18 months apart. On the first, if the conditions are met, Medicare pays and the patient owes $0. On the second, the provider expects Medicare to deny it as outside the frequency limit, unless the record supports more frequent testing, so it hands over an ABN naming the scan, giving that reason, and estimating a cost. What the estimate should be anchored to is the useful question. The Medicare anchor for an office scan is $38.75 and for a hospital outpatient scan $106.81 plus the reading, but those are what Medicare pays when it covers the test. Under the manual, after a valid ABN and a denial, the provider may charge its usual and customary fee, which none of the CMS files used here lists. So the ABN estimate is the only written number you will have; ask what it is based on, and whether it is the same price the provider charges self-pay patients for 77080 in that setting.
The choice of option then plays out like this. With Option 1, the claim goes to Medicare; if Medicare pays because the record supports the earlier scan, you owe $0 and can get back what you paid up front; if it denies, you owe the provider's charge and can appeal using the Medicare Summary Notice. With Option 2, you pay the charge and there is no claim, no notice and no appeal. With Option 3, there is no scan. Two other paths end differently. If the provider expected the denial but gave no ABN, and Medicare denies the second scan, section 50.9 relieves you of liability and the provider must refund anything it already collected. If you signed a form that was blank and filled in afterward, the manual treats it as an invalid notice, which puts you in the same position as having received none. The difference between Option 1 and Option 2 in this case is the difference between a possible $0 and a certain charge, which is why Option 1 is the only box that keeps a Medicare decision and an appeal in play.
The other Medicare notices, and what each does to what you owe
The ABN is one of a family of standardized notices, and several of them can be handed over in the same hospital stay. CMS lists them in its Beneficiary Notices Initiative. The table sets out the ones a patient can be handed in an outpatient visit, a hospital stay or post-hospital care, with the effect each has on the money.
| Notice and form | Who gives it | When | What it does to what you owe |
|---|---|---|---|
| Advance Beneficiary Notice of Noncoverage (ABN), CMS-R-131 | Providers, physicians, practitioners and suppliers, for Part B items and services and some Part A uses | Before care Medicare is likely to deny in this case | Shifts liability to you if Medicare denies and the notice was valid |
| Skilled Nursing Facility ABN, CMS-10055 | Skilled nursing facilities | Before a usually covered service that may not be covered because it is not reasonable and necessary or is custodial | Shifts liability for the facility stay or service, as the ABN does for Part B |
| Hospital-Issued Notices of Noncoverage (HINNs): HINN 1, 10, 11 and 12 | Hospitals | Before admission, at admission or during a stay, when the hospital decides care is not covered: HINN 1 before an entirely noncovered stay, HINN 11 for noncovered items within a covered stay, HINN 12 with discharge appeal notices for a noncovered continued stay, and HINN 10 when the hospital asks the QIO to review a discharge the physician did not agree with | HINN 1, 11 and 12 can shift liability for the noncovered stay, days or items; HINN 10 tells you a review has been requested |
| Medicare Outpatient Observation Notice (MOON), CMS-10611 | Hospitals | When you are an outpatient receiving observation services | Shifts nothing; tells you that you are an outpatient receiving observation services |
| Medicare Change of Status Notice, CMS-10868 | Hospitals (Original Medicare only) | When an eligible inpatient is reclassified to observation | Gives a fast appeal right; under 42 CFR 405.1211(e), a timely request means the hospital may not bill you for the disputed services until the review is complete |
| Important Message from Medicare (IM), CMS-10065 | Hospitals | During an inpatient stay | Explains discharge appeal rights |
| Notice of Medicare Non-Coverage (NOMNC), CMS-10123 | Home health agencies, skilled nursing facilities, hospices and comprehensive outpatient rehabilitation facilities | When Medicare-covered services are ending | Starts the fast appeal for ending services |
Source: CMS, Beneficiary Notices Initiative page and its HINN subpage, checked October 28, 2026.
Show the notices by stage
| Stage | Notice | Type |
|---|---|---|
| Before an outpatient service | ABN (CMS-R-131) | Shifts liability |
| Hospital stay | HINN 1, 11 | Shifts liability |
| Hospital stay | MOON (CMS-10611) | Informs |
| Hospital stay | Important Message (CMS-10065) | Appeal rights |
| Status change or discharge | Change of Status Notice (CMS-10868) | Appeal rights |
| Status change or discharge | HINN 12 | Shifts liability |
| Status change or discharge | HINN 10 | Review requested |
| After the hospital | SNF ABN (CMS-10055) | Shifts liability |
| After the hospital | NOMNC (CMS-10123) | Appeal rights |
The practical sorting rule is in the last column of the table. Three kinds of notice, the ABN, the SNF ABN and the liability HINNs, are the ones that can make you responsible for a bill Medicare does not pay, and each has its own validity rules; the ABN's are the subject of this guide. The others either tell you something about your status or open an appeal. Signing any of them acknowledges receipt; it is the liability notices where the signature, and for the ABN the option box, carries money with it. For the observation and status-change notices in particular, the observation versus inpatient guide explains what each one means for the hospital bill and for skilled nursing coverage.
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.
A rented CPAP after the 12-week trial
Medical equipment suppliers use the ABN too. For a CPAP, the DME MAC policy article says that when continued coverage after the first three rental months is not documented, the supplier marks those claim lines GA if it holds a valid ABN and GZ if it does not, and the difference decides whether you can be billed for the denied months. The CPAP rental cost guide prices each of the 13 rental months from the 2026 DMEPOS fee schedule and explains where the trial falls inside them.
An upgraded home oxygen system
Oxygen suppliers face a narrower rule. The DME MAC oxygen policy article says a supplier may not switch you to a different type of oxygen system during the rental unless it replaces like with like, a treating practitioner orders the change, CMS or the DME MAC approves it, or you choose an upgrade and sign an ABN. Signing for an upgrade does not restart the 36-month rental. The home oxygen cost guide prices the 36 rental months and what still bills in years four and five.
Chiropractic visits that turn into maintenance
Chiropractic is a common place to meet an ABN, because the Medicare Benefit Policy Manual, chapter 15, section 240.1.3, treats maintenance manipulation as not covered and tells chiropractors who give an ABN to put a GA modifier on the claim. The chiropractor's exam and X-rays are different: they fall outside the chiropractic benefit, so an ABN for them is optional. What Medicare pays a chiropractor per visit prices the covered codes and sets out which lines need a notice before you can be billed.
What to ask at the desk before you sign
Six short questions cover the ground. Start with the service itself: which exact service is on the form, and why does the provider expect Medicare to deny it for you? Then the money: what is the estimate based on, and is it the provider's usual fee or a Medicare amount? If you choose Option 1, will the office ask you to pay now, and will it refund you if Medicare pays?
Then the alternatives and the paperwork. Is there a covered alternative at a different frequency or in a different setting that Medicare would pay for? That is a billing question, not a medical one; your clinician decides what care you need. Will you get a copy of the signed form? And who bills, and whom do you 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.
Next step for a planned procedure: if you are facing an ABN, 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.
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, for example 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 for no estimate being available, a case CMS says it does not expect to be routine. 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 40.2.2 (generic, blanket and signed-blank notices) and section 50 (ABN scope, uses, optional uses, issuance, standards, effective delivery, effects of lack of notice, special considerations); Rev. 12934 table of contents, issued October 31, 2024. Checked October 28, 2026.
- CMS, Form Instructions for the Advance Beneficiary Notice of Noncoverage (ABN), estimated cost section. Checked October 28, 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 28, 2026.
- Medicare.gov, Costs, for Original Medicare cost sharing (2026 Part B deductible $283, then usually 20% coinsurance). Checked October 28, 2026.
- Electronic Code of Federal Regulations, 42 CFR 405.1211(e): no billing for disputed services during a timely expedited review after a change of status. Checked October 28, 2026.
- Medicare.gov, Bone mass measurements: once every 24 months, or more often if medically necessary, and $0 with assignment. Checked October 28, 2026.
- CMS PFS relative value file RVU26D with 2026 GPCIs (Michigan Locality 01, $33.4009) and CMS OPPS October 2026 Addendum B, for the CPT 77080 anchors. Recomputed October 28, 2026.
- CMS, Beneficiary Notices Initiative and its HINN page: form numbers, issuers and purposes of each notice. Checked October 28, 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.