Georgia Medicare ABN Advance Beneficiary Notice 2026

If a Georgia doctor, therapist, or supplier hands you a Medicare Advance Beneficiary Notice of Noncoverage (ABN) and asks you to sign, signing does not mean you owe the bill.1 An ABN is an advance warning, not a Medicare denial. It tells you that Medicare usually covers this item or service but is expected to deny it in your specific case, and it asks you to choose how you want to proceed.

The most important thing to know is what happens after you sign. If you pick the first option, the provider still bills Medicare for an official decision, and if Medicare denies payment you keep the right to appeal. You become responsible for paying only if Medicare actually denies the claim. Across Georgia, ABNs show up most often at outpatient therapy that has hit a plateau, routine foot care, and care that is shifting from skilled to custodial.

This guide explains, in plain terms, what a Georgia Medicare ABN is, the three options on the form and which one most people should pick, when a provider must give you one versus when it is just a courtesy, the billing codes that follow, the other Medicare notices it is often confused with, and exactly where in Georgia to get free help.

What a Georgia Medicare ABN (Advance Beneficiary Notice) is

The Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, is a written notice a provider, practitioner, or supplier gives an Original Medicare (fee-for-service) beneficiary before furnishing an item or service that Medicare usually covers but is expected to deny in this instance, for example as "not reasonable and necessary." Its purpose is to transfer the potential financial liability to you if you choose to go ahead anyway.1

Federal law generally protects you from owing for care Medicare denies when you had no way to know it would not be covered. The ABN is how a provider removes that "I had no way to know" protection for the one service it describes: once you have been told in advance and signed, you have been put on notice.

An ABN is not itself an official Medicare denial. You sign it to confirm you read and understood it and to pick one of three options. A properly completed form is meant to name the specific service, give the specific reason Medicare is expected to deny it, and state a good-faith estimate of what you would be charged, so a notice that leaves those blank or fills them with boilerplate is one to question.

If you are on Medicare Advantage, this is not your form

The ABN applies only to Original Medicare. It is not used for items and services under Medicare Advantage (Part C) or the Part D prescription drug benefit, which use their own notices.1 If you are in an Advantage plan and someone hands you a CMS-R-131 ABN, that is a sign of a mix-up worth questioning, because your plan should be using its own coverage and denial notices instead.

The three options on the form, and which one to pick

You must choose exactly one of three options and sign. The choice controls both who pays and whether you can appeal.1

Option 1: receive the service and have Medicare billed. You get the item or service, the provider submits a claim to Medicare, and Medicare makes an official decision. If Medicare denies, you are responsible for payment, but because a claim was submitted you can appeal. This is the right choice for most people facing an ABN, because it costs nothing extra up front beyond the contingent liability, and it preserves your appeal rights.2

Option 2: receive the service but do not bill Medicare. You get the item or service and agree to pay, and the provider does not submit a claim. Because Medicare never makes a decision, you cannot appeal.

Option 3: decline the service. You do not get the item or service, you owe nothing, and there is nothing to appeal.

If Medicare does deny a claim under Option 1, you can appeal through five successive levels: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, a hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and finally judicial review in federal court.2 You do not have to go past the level that resolves your case.

Watch the deadlines. You have 120 days from receiving the initial claim decision, which reaches you on your Medicare Summary Notice, to ask the Medicare Administrative Contractor for a redetermination, and it generally decides within 60 days. You then have 180 days from that decision to ask a Qualified Independent Contractor for a reconsideration. The first level has no minimum dollar amount, which matters for ABN disputes, because in 2026 an Administrative Law Judge hearing requires at least $200 in controversy and judicial review requires at least $1,960.2

When a provider must give you an ABN

A provider is required to issue an ABN when it believes Medicare will likely deny a service it would otherwise cover, typically because the service is not "reasonable and necessary" for your situation or because care has become custodial rather than skilled. The most common mandatory triggers in Georgia are these.

Outpatient therapy past a plateau

Physical, occupational, and speech therapy are covered by Medicare Part B when medically necessary, with no lifetime cap; above an annual threshold, $2,480 in 2026 for physical and speech therapy combined and a separate threshold for occupational therapy, the therapist must add a modifier attesting in the record that continued therapy is still medically necessary.4 When a clinic concludes that more therapy will not help, it may issue an ABN before the next session.

Important nuance: coverage does not depend on whether you are still improving. Under the Jimmo v. Sebelius settlement, Medicare covers skilled therapy and skilled nursing when the skill of a professional is needed to maintain your condition or to slow decline, not only when you are expected to get better.5 The old "you must keep improving to keep coverage" rule is a myth. If an ABN was issued only because you stopped improving, that is worth questioning, because maintenance care can still be covered. Every other coverage rule still applies, though: the care must genuinely require the skill of a professional and be reasonable and necessary.5

Routine foot care without a qualifying condition

Medicare generally does not pay for routine foot care, such as cutting or removing corns and calluses or trimming nails, and you pay the full cost.6 There is an exception: routine foot care can be covered when a systemic condition like diabetes-related nerve damage or peripheral vascular disease makes it medically necessary for a professional to perform. When that exception does not apply, a podiatrist will often issue an ABN before trimming nails so you know Medicare is expected to deny. Two things are covered here that people miss: medically necessary foot treatment, for a problem like a hammer toe, a bunion deformity, or a heel spur, is covered under Part B at 20 percent coinsurance after the deductible, and if you have diabetes-related nerve damage with loss of protective sensation, Part B covers a foot exam every six months as long as you have not seen a foot care professional for another reason in between.6

Care shifting from skilled to custodial

Medicare Part A covers skilled nursing facility care only on a short-term, post-acute basis and never pays for long-term custodial care, the non-skilled help with daily activities like bathing and dressing.7 When a skilled nursing facility determines that your skilled need has ended and remaining care is custodial, it issues a notice that Medicare coverage is ending, and you decide how to pay for any continued custodial care through private pay, long-term care insurance, or Medicaid if you qualify.

When an ABN is just a courtesy (voluntary)

For services Medicare never covers, an ABN is optional. Original Medicare excludes several categories families often assume are covered: most routine dental care, routine vision care and eyeglasses, hearing aids and the exams to fit them, cosmetic surgery, care not provided within the United States, and routine foot care.8

Do not treat those categories as closed, because several carry real exceptions. Medicare does cover one pair of conventional eyeglasses or contact lenses after each cataract surgery with an intraocular lens. It does cover dental care that is inextricably linked to a covered medical service, which as the rule now stands reaches the dental exam and infection treatment done before or alongside an organ, stem cell, or bone marrow transplant, a cardiac valve replacement or valvuloplasty, chemotherapy or CAR T-cell therapy for cancer, treatment of head and neck cancer, and Medicare-covered dialysis. Cosmetic surgery is excluded except where it is required for the prompt repair of an accidental injury or to improve the functioning of a malformed body part. And routine foot care can be covered when a systemic condition makes professional care necessary.8

Where a service genuinely is excluded, the provider was never going to get Medicare to pay, so issuing an ABN is a courtesy to document that you were told. With a voluntary ABN you are responsible for the cost no matter what, and there is no Medicare denial to appeal. A Medicare Advantage plan may offer supplemental benefits, meaning services in addition to those Medicare covers, and that is how an Advantage plan can provide dental, vision, or hearing coverage Original Medicare excludes; whether a given plan offers such benefits, and how much they cover, varies by plan.8

GA, GZ, and GX: the billing codes on your claim

After an ABN situation, the provider adds a short billing code, called a modifier, to the Medicare claim to signal what happened. In plain terms: a GA modifier means a required ABN is on file and liability was transferred to you; a GZ modifier means an ABN should have been issued but was not, which flags the claim for denial and leaves the provider holding the cost, because liability shifts to you only where you were given written advance notice;1 and a GX modifier means a voluntary ABN was issued for a service Medicare never covers. You do not file these codes yourself, but seeing GA versus GZ on your paperwork tells you whether the provider claims an ABN is on file.

Other Medicare notices people confuse with the ABN

The ABN is one of several Medicare notices, and they are easy to mix up because they all involve coverage ending or being denied.

• Notice of Medicare Non-Coverage (NOMNC). You get this when a covered service such as a skilled nursing, home health, or hospice service is about to end. It gives you the right to a fast appeal through a Beneficiary and Family Centered Care Quality Improvement Organization, the contractor that reviews these terminations.9 The provider must give it to you at least two days before the services end, and the deadline to act is tight: follow the instructions on the notice and file no later than noon the day before the termination date it lists.10
• Medicare Outpatient Observation Notice (MOON). A hospital must give you this when you have been getting outpatient observation services for more than 24 hours, no later than 36 hours after observation begins, because observation is outpatient and does not count toward the three-day inpatient stay Medicare requires before it will cover skilled nursing facility care.11
• Hospital-Issued Notice of Noncoverage (HINN) and skilled nursing facility notices. These tell you that an inpatient hospital stay or a skilled nursing stay is no longer covered at that level, and like the NOMNC they can trigger a Quality Improvement Organization review. If you believe a hospital is discharging you too soon, follow the instructions on the Important Message from Medicare and request the fast appeal no later than the day you are scheduled to be discharged.10

The plain difference: an ABN warns you before a service that Medicare is expected to deny, while these other notices tell you a service Medicare has been covering is ending.

If your ABN looks wrong: defective notices and your refund right

Liability shifts to you only because you were given written notice in advance that the service did not meet Medicare's coverage guidelines.1 So a defectively issued ABN does not transfer liability to you, and when Medicare denies the claim the provider generally absorbs the cost instead.

The signs that an ABN may not hold up: it was handed to you after the service was already provided, the "reason Medicare may not pay" field is generic boilerplate instead of a specific reason, it carries no good-faith cost estimate, it is missing your signature, or you were pressured into a particular option rather than given a genuine choice. Medicare's refund rules can also require a physician who does not accept assignment to refund what you already paid when Medicare denies the service as not reasonable and necessary, subject to that rule's exceptions, which include cases where you were given proper advance notice and agreed to pay.1 If you think your ABN was defective, do not assume you owe the bill before you ask.

Worked examples: ABNs in Georgia

The following examples are illustrative scenarios, not real cases, and any dollar figures a provider would put on the form depend on its own charges.

Outpatient therapy after a knee replacement (Fulton County)

A 70-year-old in Fulton County has been getting outpatient physical therapy after a total knee replacement. Three months in, the clinic documents a functional plateau and believes Medicare will deny continued sessions, so before the next visit it issues an ABN naming the specific service, the reason, and an estimated cost. She picks Option 1, so the clinic bills Medicare with a GA modifier. If Medicare denies, she owes the charge but can appeal, and because skilled maintenance therapy can still be covered, the plateau by itself is not a valid reason for the denial. The appeal still has to show that the therapy needed a professional's skill and was reasonable and necessary.5

Routine toenail trimming (DeKalb County)

A 75-year-old in DeKalb County sees a podiatrist for routine nail trimming and has no diabetes or circulatory disease that would qualify for the exception. The podiatrist issues an ABN before the service. She picks Option 1, Medicare denies the claim as expected, and she pays the routine-care charge but received clear advance notice of the cost.6

A cosmetic procedure (Cobb County)

A 68-year-old in Cobb County wants a cosmetic eyelid lift with no medical indication. Medicare excludes cosmetic surgery except where it is required for the prompt repair of an accidental injury or to improve the functioning of a malformed body part, and neither applies here, so the surgeon issues a voluntary ABN as a courtesy. She is fully responsible for the cost, and because the service is excluded there is no Medicare denial to appeal.8 The same procedure done to restore a function rather than an appearance is a different question, and worth asking about before you accept that it is uncovered.

A skilled nursing stay turning custodial (Bibb County)

An 80-year-old in Bibb County is on day 25 of a skilled nursing facility stay after a hospital discharge. The skilled need has resolved and remaining care is custodial, so the facility issues a notice that Medicare coverage is ending. The family arranges continued custodial care through private pay or, if he qualifies, Medicaid.7

Georgia Medicare ABN, Advance Beneficiary Notice: who to call for help

You do not have to sort this out alone. Free, unbiased help is available in Georgia.

• Georgia SHIP, which the state also lists as GeorgiaCares SHIP, the state's free Medicare counseling program. It is Georgia's State Health Insurance Assistance Program, a volunteer-based program run by the Division of Aging Services. It is not affiliated with any insurance company, and its certified counselors do not sell or solicit insurance. They give free, unbiased help with plan choices, enrollment, reviewing Medicare Summary Notices, sorting through medical bills, and filing Medicare claims and appeals, Monday through Friday, 8 a.m. to 5 p.m., at 1-866-552-4464 (option 4).3
• Palmetto GBA, the Medicare claims contractor for Georgia. Original Medicare claims and ABN-related denials in Georgia are processed by Palmetto GBA, and a first-level appeal (redetermination) is filed with it.
• Acentra Health, the Quality Improvement Organization. If you receive a NOMNC, HINN, or other service-termination notice and disagree, Acentra Health (formerly Kepro) is the BFCC-QIO for Georgia that reviews these fast appeals; its Beneficiary Helpline is 1-888-317-0751.12
• The Medicare Beneficiary Ombudsman. The Ombudsman helps with Medicare complaints, grievances, and information requests; reach it by asking a representative at 1-800-MEDICARE (1-800-633-4227) to submit your inquiry. It advocates and informs, but does not itself decide appeals.9,13

Resources and contacts

Learn more

Find personalized help navigating Medicare ABN questions at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.