Overview
The Advance Beneficiary Notice of Noncoverage, commonly called an ABN, is CMS Form R-131. Providers and suppliers use it with Original Medicare Fee-for-Service when they have a specific basis to expect that Medicare may not pay for an otherwise covered item or service for a reason to which the financial-liability notice rules apply. Medicare Advantage uses the member plan's organization-determination and notice process instead. Items or services that are never a Medicare benefit generally follow a voluntary-notice path; a commercial payer's noncoverage or financial-consent document is not CMS-R-131.
The ABN records three distinct beneficiary choices. Option 1 means the beneficiary wants the identified item or service and wants a Medicare claim submitted, preserving the opportunity for a Medicare determination and appeal; the beneficiary may owe if Medicare denies. Option 2 means the beneficiary wants the item or service but does not want a Medicare claim submitted and therefore gives up the Medicare appeal path for that claim. Option 3 means the beneficiary declines the identified item or service. The notifier must not preselect an option or prefill the beneficiary or representative signature and date.
A compliant workflow uses the current approved form, identifies the specific item or service, states a genuine and understandable expected-denial reason, and provides a good-faith estimated cost. Delivery must occur before the item or service, with enough time and explanation for an informed decision. Blank, generic, blanket, routine, retroactive, coercive, or emergency-delivered notices are not a substitute for patient-specific review. If a diagnosis, service definition, coverage detail, or policy match is missing or uncertain, the appropriate response is a provider query or qualified staff review—not invention of a clinical fact.
For laboratory testing, the order may need to be matched to the beneficiary's line of business, service date, Medicare Administrative Contractor jurisdiction, applicable NCD or LCD and related billing article, diagnosis and documentation criteria, and available frequency history. NCCI procedure-to-procedure edits and Medically Unlikely Edits are coding controls; they do not independently create a medical-necessity ABN basis. When the person who gives the notice is not the entity that bills Medicare, the signed record should be routed to the billing entity.
Electronic issuance is permitted, but the beneficiary must be offered paper issuance and should receive a paper copy of the signed ABN. The notifier generally retains the record for five years from discharge or completion of delivery of care, subject to longer applicable requirements. GA, GX, GY, and GZ modifier use depends on the actual notice and claim circumstances and should be validated by authorized billing staff. A properly delivered notice can support a liability determination, but the software or notifier does not make Medicare's official coverage decision or guarantee that liability will transfer.
Worked example
A laboratory receives an Original Medicare FFS order for a test whose current, jurisdiction-specific coverage guidance does not support the documented diagnosis. Before collection, staff validate the source and service date, present a test-specific ABN with the expected-denial reason and a good-faith estimate, and explain all three options. The beneficiary selects Option 1 and signs; the reviewed notice is retained and routed with the billing record for authorized claim handling.
Frequently asked questions — Advance Beneficiary Notice
When is an ABN required?
Before furnishing a Medicare-covered service that is likely to be denied for medical necessity, frequency limits, or specific LCD/NCD non-coverage. ABNs are not required for services that are statutorily excluded (those may use a voluntary ABN with modifier GX) or for Medicare Advantage members (separate MA notice rules apply).
Can we have patients sign ABNs routinely?
No. CMS treats blanket ABNs — those used for every patient or every service — as invalid. An ABN must name a specific service and a specific reason denial is expected. Routine ABN use is a common audit finding and shifts liability back to the provider.
What is the difference between ABN modifiers GA, GX, GY, and GZ?
GA indicates that a required waiver-of-liability statement is on file; GX indicates that a voluntary notice was issued; GY identifies an item or service that is statutorily excluded or does not meet a Medicare benefit definition; and GZ indicates an item or service expected to be denied as not reasonable and necessary when no signed ABN is on file. Staff must apply modifiers to the actual claim and notice circumstances rather than infer them from an automated risk result.
How long should ABNs be retained?
CMS guidance states that the general retention period is five years from discharge or completion of delivery of care when no other state-law requirement applies. A longer federal, state, contractual, litigation-hold, or organizational requirement may control.
Disclaimer
This glossary entry is operational reference for revenue-cycle and medical-billing professionals. It is not legal, clinical, or contractual advice. Industry benchmarks cite named public sources where available; always verify against the current guidance from the authority body before relying on a number in a contract, policy, or compliance filing.