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.1 In Georgia, as everywhere, ABNs can come up with outpatient therapy a clinic no longer considers medically necessary, routine-looking foot care, and care that is shifting from skilled to custodial.

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 because it is not medically necessary or counts as custodial care. 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.1 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 pick one of three options on the form and sign it.1 A notice that holds up names the specific service and the reasons Medicare is expected to deny it, so one that leaves those blank or fills them with boilerplate is one to question.1

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: CMS instructs providers not to use an advance notice of non-coverage for those.1 If you are in an Advantage plan and someone hands you a CMS-R-131 ABN, that is a mix-up worth questioning: Advantage disputes start with the plan's own denial notice.2

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. If Medicare does pay, the provider refunds anything you already paid, apart from copayments or deductibles.1 This is the right choice for most people facing an ABN, because it is the only option that both gets you the service and preserves your appeal rights.1,2

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.1

Option 3: decline the service. You do not get the item or service, you owe nothing, and there is nothing to appeal.1

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.1 Three situations where that can come up are these.

Outpatient therapy the clinic no longer considers necessary

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 $2,480 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 continued therapy is no longer medically necessary, it may issue an ABN before the next session.1

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 CMS says providers and contractors may have wrongly believed improvement was required; the settlement clarified existing policy rather than changing it.5 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-looking foot care that may not meet an exception

Medicare generally does not pay for routine foot care, such as cutting or removing corns and calluses or trimming nails, and in most cases you pay the full cost.6 The exceptions reach beyond diabetes: routine-looking care can be covered when it is a necessary part of treating an ulcer, wound, or infection; when a systemic condition, such as diabetes, arteriosclerosis obliterans, or certain peripheral neuropathies, makes it hazardous for a non-professional to do; and, for fungal toenails a doctor documents as causing pain, infection, or marked trouble walking, even without a systemic condition. Covered routine care costs 20 percent of the Medicare-approved amount after the Part B deductible.6 When a podiatrist expects Medicare to find that no exception applies in your case, for example because no qualifying condition is documented, it may give you an ABN before the service.1,6 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 does not pay 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 must give you a Notice of Medicare Non-Coverage at least two days before covered services end.8 In a skilled nursing facility, the ABN itself is used only for Part B items and services the facility expects Medicare to deny.1 Medicare does not pay for continued custodial care, so you cover it through private pay, private long-term care insurance, or Medicaid if you meet its eligibility rules.7

When Medicare excludes the service outright

The ABN is the notice for items and services Medicare usually covers but is expected to deny in your case, so it is not built for services Medicare excludes outright.1 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, most care not provided within the United States, and routine foot care unless an exception applies.9

Several of those categories 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, including, among other situations, the dental exam done as part of the workup before, and the treatment to clear a dental infection before or alongside, an organ, stem cell, or bone marrow transplant, a cardiac valve replacement or valvuloplasty, chemotherapy, CAR T-cell therapy, or high-dose bone-modifying drugs used to treat cancer, and Medicare-covered dialysis; for head and neck cancer it also reaches treating dental complications afterward. 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 the routine foot care exclusion has its own exceptions: treating warts is not excluded, and neither is foot care done as a necessary part of a covered procedure on the foot.9

Where a service genuinely is excluded and none of these exceptions fits, you pay all costs for it, because Medicare does not cover it.7 A Medicare Advantage plan (other than a Medical Savings Account 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.9

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.10 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.8
• 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 or at your release if that comes sooner, because observation is outpatient and does not count toward the three-day inpatient stay Medicare generally requires, unless a waiver applies, before it will cover skilled nursing facility care.11
• An Important Message from Medicare about Your Rights. In a hospital you should get this notice within two days of your admission and before your discharge, and it explains how to ask the Quality Improvement Organization for a fast appeal of your discharge.12 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.8

The plain difference: an ABN warns you before a service that Medicare is expected to deny, while the NOMNC and the Important Message tell you covered care is ending, and the MOON tells you that you are an outpatient.

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

Under Medicare's limitation-on-liability rules, you are treated as having known a service was not covered when you were given written notice that it did not meet Medicare's coverage guidelines, from the provider or a Medicare contractor. An earlier written notice about similar services, or about the same non-covered condition, can also count.1 So a defectively issued ABN does not by itself shift liability to you, and unless an earlier notice already put you on notice, Medicare can hold the provider liable and bar it from collecting from you when the notice was not issued or is found invalid.1

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, or it is missing your signature. Medicare's refund rules can also require a physician who does not accept assignment to refund what you already paid for an otherwise covered service when Medicare denies it as not reasonable and necessary. The refund is excused only if the physician could not reasonably have known, or warned you in writing beforehand, naming the service and why Medicare would likely deny it, and you signed an agreement to pay. A notice handed to every patient, or one saying only that Medicare might not pay, does not count.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 and the reason. She picks Option 1, so the clinic bills Medicare. If Medicare denies, she owes the charge but can appeal, and because coverage turns on her need for skilled care rather than on her potential to improve, the plateau by itself does not decide whether the therapy is covered. 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, circulatory disease, painful or infected fungal nails, or wound the podiatrist can document, so it expects Medicare to deny and gives her an ABN before the service. She picks Option 1, so Medicare makes the call: it denies the claim as expected, and she pays the routine-care charge, but she knew the cost in advance and kept the right to appeal.6,1

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.9 That makes this an excluded service, not a usually covered one Medicare is expected to deny, which is what an ABN warns about.1 She pays all costs for it, because Medicare does not cover it.7 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 gives him a Notice of Medicare Non-Coverage at least two days before covered services end.8 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. Palmetto GBA processes Original Medicare Part A and Part B claims in Georgia and decides the first-level appeal (redetermination) of a denial. Durable medical equipment claims go to a separate contractor, CGS Administrators.13
• Acentra Health, the Quality Improvement Organization. If you receive a NOMNC, the hospital's Important Message from Medicare, or another notice that your covered care is ending and you 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 assists and informs, including helping you collect information to seek an appeal, but it is not itself one of the appeal levels.10,14

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.