Advance Beneficiary Notice (ABN): What It Means and What to Do

You're at a doctor's appointment with your parent when a staff member hands them a form to sign before the doctor will proceed. The form is labeled "Advance Beneficiary Notice of Noncoverage" — or ABN. Nobody explains it properly. The nurse just says they need a signature.

This moment trips up many families. Some parents sign reflexively, not realizing they've just agreed to pay out of pocket for something Medicare might actually cover. Others refuse to sign, delaying or forfeiting needed care.

Here is what you need to know about the ABN before you or your parent are ever in that room.

What an ABN Actually Is

An Advance Beneficiary Notice of Noncoverage (ABN) — officially CMS form R-131 — is a written notice that a Medicare-participating provider must give a beneficiary when the provider believes Medicare will likely deny payment for a specific item or service.

The key word is "likely." The provider is not telling your parent that Medicare won't pay — they are telling your parent that they expect Medicare won't pay and want to make sure your parent knows they would be responsible for the cost if Medicare does deny the claim.

ABNs are required in Original Medicare only. Medicare Advantage has a different parallel process (discussed below).

The ABN must be given before the service is provided — not after. It must be specific about what service is in question, why the provider thinks Medicare won't cover it, and an estimated cost. A blank form handed to your parent for a signature is not a valid ABN.

When Providers Are Required to Issue an ABN

A provider must issue an ABN whenever they have a genuine reason to believe Medicare will deny a claim. Common scenarios include:

Frequency issues: Medicare covers some services based on frequency guidelines. For example, Medicare generally covers a physical therapy session at a specific frequency — if your parent's doctor wants to continue therapy beyond what Medicare typically approves, an ABN is required to notify your parent before that session.

Medical necessity concerns: If a test or procedure is not clearly supported by the documented diagnosis (for example, ordering an MRI for a low-acuity condition), the provider expects Medicare may flag it as not medically necessary.

Non-covered services: Routine items like certain footcare, custodial home health services, or comfort items that fall outside Medicare's benefit categories. These are not covered by Medicare, period — not a coverage dispute. ABNs for clearly non-covered services are sometimes issued but are technically not required.

Maintenance therapy: Medicare once excluded "maintenance" physical or occupational therapy (care to maintain, not improve, function). This changed with the Jimmo v. Sebelius settlement — Medicare now covers maintenance therapy if skilled care is needed. However, some providers still issue ABNs in this context out of habit or misunderstanding. This is worth pushing back on.

The Three Options on the ABN

The ABN form gives your parent three choices. Understanding what each means is important before signing:

Option 1: "I want [the service]. I understand Medicare may not pay, and I will be responsible for payment. I may appeal."

Signing this means your parent receives the service, the provider bills Medicare, and if Medicare denies the claim, your parent pays. Importantly, if they sign Option 1, the claim is still submitted to Medicare — and your parent retains the right to appeal a denial.

Option 2: "I want [the service], but I do not want Medicare billed. I will pay out of pocket."

This is rarely the right choice. Choosing this option means the provider does not bill Medicare at all. Your parent pays the full private-pay rate — which is often much higher than the Medicare-approved rate — and cannot appeal because no claim was submitted. This option mainly benefits the provider, not the patient.

Option 3: "I do not want [the service]."

Your parent refuses the service. The provider documents the refusal. No billing occurs.

In most cases, Option 1 is the correct choice. It preserves your parent's rights, allows the claim to go through Medicare, and allows an appeal if Medicare denies it.

What to Do When Your Parent Is Given an ABN

Do not sign immediately. Take these steps:

1. Read the form carefully. Confirm it is completed — not blank. The form must specify the exact service, the estimated cost, and the reason the provider thinks Medicare won't cover it.

2. Ask the provider why. "Why do you think Medicare won't cover this?" is a completely reasonable question. The answer tells you a lot. If the answer is a frequency or documentation issue, ask whether the documentation can be updated to support medical necessity. Sometimes the problem is correctable before billing.

3. Call Medicare if time permits. For non-urgent situations, call 1-800-MEDICARE (1-800-633-4227) and ask whether the described service should be covered given your parent's diagnosis and treatment history. Medicare representatives can give general guidance, though they cannot guarantee coverage for a specific claim.

4. Check your parent's current coverage. If your parent has a Medigap policy, confirm whether it would pay the coinsurance if Medicare approves the claim — or cover the full cost if Medicare denies it (Medigap does not typically cover non-covered services, but it does cover cost-sharing for approved services).

5. Sign Option 1 and proceed with the service if it is medically necessary. The ABN does not mean the service will definitely be denied — it means the provider has flagged a risk. The actual claim may be approved.

If Medicare Denies the Claim

If your parent signed Option 1 and Medicare still denies the claim, they have the right to appeal. The appeals process begins with a redetermination request filed within 120 days of the denial notice. This is where having signed Option 1 matters — the claim must have been submitted to Medicare for an appeal to be possible.

Grounds for a successful appeal often include:

• Medical necessity documentation the provider's billing department did not include with the original claim
• Evidence that the service met Medicare's coverage criteria despite the provider's concern
• For therapy claims: documentation that skilled care is required to maintain (not just improve) function

Over 80% of denied claims that reach an independent review level are eventually overturned. The process takes persistence but is worth attempting before paying out of pocket for a significant medical expense.

When ABNs Are Used Improperly

Not every ABN handed to a patient is legitimate or required. Some patterns to watch for:

Blanket ABNs: Some practices routinely give ABNs to all Medicare patients as a matter of policy, covering all services. This is not permitted under Medicare rules. An ABN must be specific to a particular service that the provider has a genuine reason to believe will be denied.

ABNs used to avoid billing Medicare: Some providers prefer not to deal with Medicare's billing system and use ABNs as a way to shift all costs to patients. This is a Medicare compliance violation. If your parent is seeing a provider who participates in Medicare, that provider is required to attempt to bill Medicare for covered services.

Using an ABN to mask upcoding: In some fraud cases, providers give ABNs for services they plan to bill Medicare for at a higher complexity level — essentially double-dipping. If your parent receives an ABN and then later sees that Medicare was billed anyway (visible on their Medicare Summary Notice), report it.

Medicare Advantage: The Similar But Different Process

Medicare Advantage (Part C) plans do not use the ABN form. Instead, they use a Notice of Medicare Non-Coverage (NOMNC) for service terminations (like when a skilled nursing facility says Medicare Advantage coverage is ending) or a Coverage Determination process for prior authorization denials.

If your parent's Medicare Advantage plan denies a prior authorization or ends coverage for an ongoing service, they receive a written denial that functions similarly to a claims denial under Original Medicare — and the appeals process follows the MA appeals structure rather than the ABN/Medicare claims process.

Practical Takeaways

• An ABN is a warning, not a final decision. Medicare may still cover the service.
• Always sign Option 1 (not Option 2) to preserve the right to have the claim submitted and appealed.
• Read the form before signing — a blank or incomplete ABN is not legally valid.
• Ask why the provider expects Medicare to deny coverage, and whether documentation can be improved.
• If Medicare denies the claim after your parent signed Option 1, appeal the decision before paying.

The ABN is one of many paperwork moments where families who understand the system get better outcomes than those who don't. Knowing what to do in that office — before the nurse is standing there waiting for a signature — is the difference between protecting your parent's benefits and inadvertently waiving them.

Our Medicare Enrollment Guide covers the full scope of managing Medicare for an aging parent: from initial enrollment and plan selection through claims management, appeals, and annual renewal reviews. Understanding how the pieces fit together makes every individual moment — including the ABN conversation — much easier to navigate.