Signing an Advance Beneficiary Notice of Noncoverage (ABN) at the front desk isn't the same as agreeing you owe the money, and it doesn't cost you your right to appeal. The ABN is the written notice your Medicare provider gives you before a service the program usually covers but expects to deny this time. It hands you a choice: get the service and have your provider bill Medicare anyway, get it with no claim filed, or turn it down.

In This Guide

What Is an Advance Beneficiary Notice, Exactly?

The Advance Beneficiary Notice of Noncoverage, ABN for short, is a standard federal form: Form CMS-R-131. Your provider, practitioner, or supplier gives it to you before furnishing an item or service to an Original Medicare (fee-for-service) patient when Medicare payment is expected to be denied. That last part is the whole point of the notice, so it's worth sitting with.

The form's job is to move the potential bill onto you if you choose to go ahead. In plain terms, it's your provider saying, "Medicare probably won't pay for this, so before we do it, I need you to know you might be the one paying." It's how a provider hands you the choice before a service they expect Medicare to deny, so the decision is yours to make with your eyes open. That transfer of the bill depends on the notice being properly issued, though, and what happens when it isn't is worth knowing before you sign.

Providers, practitioners, and suppliers all use it, including independent laboratories, home health agencies, and hospices, and it's the same notice doing the same job wherever it turns up. Skilled nursing facilities issue it only for items and services expected to be denied under Medicare Part B.

Why Did You Get an Advance Beneficiary Notice?

You got an ABN for a service Medicare does normally cover. That's what makes it different from care Medicare leaves out entirely.

The ABN shows up in the in-between case: the service is generally covered, but Medicare is expected to deny it this time. A common reason is that the service isn't considered medically necessary for your particular situation, or that it counts as custodial care. In other words, your provider doesn't expect Medicare to see this service as necessary or covered for you in particular. Your provider can't promise how Medicare will rule, but they have good reason to think a denial is coming, so they give you the notice before doing the work rather than surprising you with a bill after.

If you want the bigger picture of the kinds of care Medicare leaves out entirely, see our guide on what Medicare doesn't cover. The ABN is a narrower thing: a heads-up about a covered service that may get denied in your specific case.

The Choice an ABN Asks You to Make

Read past the explanation and every ABN comes down to one boxed choice. You pick one option, sign, and that signature just says you read and understood the notice. The three options differ in one thing that matters later: whether a claim ever reaches Medicare, because that's what decides if you can appeal.

Option What you're choosing If Medicare denies, who pays Can you appeal?
Option 1 Get the service and have your provider bill Medicare You do, but a claim was filed Yes
Option 2 Get the service, but don't bill Medicare You do, up front No
Option 3 Decline the service No one, because it isn't done No

Option 1 is the one most people want, and it's easy to see why. You still get the care, and because a claim goes to Medicare, you keep the ability to appeal if Medicare denies it. You might end up paying, but you get a real shot at Medicare's decision first. The risk also runs both ways here, and this is the half of Option 1 people rarely hear at the counter: if your provider asks you to pay up front and Medicare then pays the claim, the provider or supplier refunds the payments you already made, not counting your copayments and deductibles. So a bill at the desk is not a reason on its own to decline care you actually want.

Option 2 gets you the service too, but you're telling your provider not to bill Medicare at all. You pay, and because no claim was submitted, there's nothing to appeal. Option 3 is the walk-away: you decline the service, so there's no claim, no bill, and no appeal. If you're not sure the service is worth the risk of paying out of pocket, that's a fair conversation to have with your provider before you check a box.

Does Signing an ABN Mean You Owe the Money?

This is the fear that makes people freeze at the counter, so let's be clear. Signing an ABN is not an official Medicare denial of coverage. Pick Option 1 or Option 2 and you're accepting the bill if Medicare doesn't pay. But the form itself isn't a Medicare denial, and whether you actually owe depends on the notice being valid.

And you don't give up your appeal rights by signing. If you choose Option 1, a claim goes to Medicare, and if Medicare denies payment, you have the right to file an appeal. So the practical move, if you want the service and want to preserve every right you have, is usually Option 1: get the care, let the claim go in, and appeal if it's denied. Our guide to appealing a Medicare denial walks through how that process works and the deadlines that come with it. If you can't tell which option fits, ask your provider to explain before you hand the form back.

What Should You Do When You're Handed an ABN?

You don't have to decide in a rush, and you don't have to decide alone. Read the whole form before you sign. You'll pick one option and sign, and that signature says you read and understood the notice. These questions are worth asking your provider first:

  • Which service is this for, and why do you expect Medicare to deny it in my case?
  • What will it cost me if Medicare doesn't pay?
  • If I choose Option 1, will you bill Medicare right away?
  • Is there another way to treat this that Medicare does cover?

If you're still unsure, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048). You can talk or live chat with a real person 24 hours a day, 7 days a week, except some federal holidays. You can also call your State Health Insurance Assistance Program (SHIP) for free, personalized counseling, including help with appeals. To find yours, visit shiphelp.org or call 1-877-839-2675. Some states use a different name for their SHIP.

How Do You Appeal If Medicare Denies an Option 1 Claim?

If you chose Option 1 and Medicare denies the claim, the decision comes on your Medicare Summary Notice (MSN). You can appeal any decision on it, and the last page gives step-by-step directions. The first level for Original Medicare is a redetermination by the Medicare Administrative Contractor, which you request within 120 days of receiving the notice. Appeals must be filed in writing, using the form and step-by-step directions on the last page of the notice, and the notice prints the date your appeal must be received. You can also read Medicare.gov's overview of the Original Medicare appeal levels. Our guide to appealing a Medicare denial covers the later levels.

The ABN isn't the only Medicare notice you might be handed. If skilled nursing facility, home health, or hospice services are ending, you'd instead get a "Notice of Medicare Non-Coverage," and you have the right to a fast appeal. Our fast appeal guide explains how that works.

When an ABN Does Not Shift the Bill to You

A signed form in your file is not the end of the question. The liability transfer depends on the notice being properly issued: if your provider never issued the required notice, or if the Medicare Administrative Contractor that processes the claim finds the notice invalid, CMS can hold the provider financially liable and bar them from collecting payment from you.

If your doctor doesn't take assignment (meaning they don't agree to accept Medicare's approved amount as full payment) and charged you for a covered service that Medicare then denied as not reasonable and necessary, they generally owe you that money back. They're off the hook only if they couldn't reasonably have known Medicare wouldn't pay, or if they warned you in writing beforehand and you signed a statement agreeing to pay. That warning has to be real: written in approved notice language, naming the specific service, and giving the doctor's reasons for expecting a denial. A notice handed to every patient, or one that only says Medicare might possibly not pay, doesn't count.

If you've already paid for something Medicare should have covered, there's a way back. If you had no way of knowing Medicare wouldn't cover it, and the provider, practitioner, or supplier knew or should have known, you can ask Medicare to pay you back and then collect from them. You have to ask, and the clock matters: your request is due by the end of the sixth month after the later of the month you paid or the month the contractor told you that you weren't liable. If you paid in March, for example, that means the end of September, unless the contractor's notice came later. The window can be extended if you show good cause.

None of this makes an ABN safe to shrug off. It means the form is evidence about what you were told, judged against a standard, rather than a receipt for a debt you now owe.

Does a Medicare Advantage Plan Use an ABN?

One boundary trips people up, so it's worth stating plainly. The ABN is an Original Medicare form. CMS instructs providers not to use an advance written notice of noncoverage for items and services provided under Medicare Advantage (Part C) or the Part D prescription drug benefit.

So if your coverage is a Medicare Advantage plan rather than Original Medicare, the CMS-R-131 form isn't meant for your plan's items and services, and its rules don't automatically describe how your plan handles a coverage question. For plan-specific issues, CMS directs you to call your plan first, using the number on your member ID card. If the plan can't resolve it, 1-800-MEDICARE can help. What this article covers is the Original Medicare ABN.

Frequently Asked Questions

What is a Medicare ABN?

It's an Advance Beneficiary Notice of Noncoverage, Form CMS-R-131. Your provider gives it to you before a service Original Medicare usually covers but is expected to deny in your case, so you can decide whether to go ahead knowing you might have to pay.

Does signing an ABN mean I have to pay?

No, not by itself. An ABN isn't an official Medicare denial. It means you were warned that Medicare may not pay. If you choose the option where a claim is still submitted to Medicare and Medicare denies it, you're responsible for the cost, but you can appeal that decision first. If Medicare pays instead, your provider or supplier refunds any payments you already made, not counting your copayments and deductibles. And if the required notice was never issued, or the Medicare Administrative Contractor finds it invalid, CMS can hold the provider financially liable and bar them from collecting payment from you.

Does an ABN waive my right to appeal?

No. If you pick the option to receive the service and have your provider bill Medicare, a claim goes in, and you keep the right to appeal if Medicare denies payment. You only lose the ability to appeal if you choose an option where no claim is submitted.

What are the three options on an ABN?

Option 1: get the service and have your provider bill Medicare, which is the only option that keeps your right to appeal a denial (and if Medicare pays, your provider refunds anything you paid up front, apart from copayments and deductibles). Option 2: get the service but don't bill Medicare (you pay and can't appeal). Option 3: decline the service (nothing is billed and there's nothing to appeal).

Is a signed ABN always enough to make me pay?

No. The transfer of liability depends on the notice being properly issued. If your provider didn't issue the required notice, or the Medicare Administrative Contractor finds the notice invalid, CMS can hold the provider financially liable and bar them from collecting payment from you. A doctor who doesn't take assignment also can't rely on a notice given routinely to every patient, or one saying no more than that Medicare might not pay.

How do I appeal after choosing Option 1?

If Medicare denies the claim, look at the last page of your Medicare Summary Notice for the directions. The first level is a redetermination by the Medicare Administrative Contractor, requested within 120 days of receiving the notice. You can call 1-800-MEDICARE or your SHIP for help before you file.

What if I already paid for something Medicare should have covered?

If you had no way of knowing Medicare wouldn't cover it, and the provider, practitioner, or supplier knew or should have known, you can ask Medicare to pay you back and then collect from them. The request is due by the end of the sixth month after the later of the month you paid or the month the contractor told you that you weren't liable (pay in March and it's the end of September), and good cause can extend it.

Does Medicare Advantage use an ABN?

No. CMS instructs providers not to use an advance written notice of noncoverage, like the ABN, for items and services under Medicare Advantage (Part C) or Part D. If you disagree with a Medicare Advantage plan's denial, the appeal starts with the plan itself, and you generally have 65 days from the date on the plan's denial notice to file (a reason is needed if you file late). Check your plan's materials for how it handles a coverage question.

Learn More

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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.

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