Form · Medicare

ABN form (Advance Beneficiary Notice of Non-coverage, CMS-R-131)

What it is, who uses it, and field-by-field help. Publisher: CMS. Links checked October 23, 2026.

Quick answer

The Advance Beneficiary Notice of Non-coverage (ABN, form CMS-R-131, OMB 0938-0566) is the notice a provider or supplier gives an Original Medicare patient before an item or service Medicare is not likely to cover, so the patient can decide whether to get it and accept that they may have to pay. It must be delivered before the service, never in an emergency.

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At a glance

Form: CMS-R-131, Advance Beneficiary Notice of Non-coverage
OMB number: 0938-0566
Who gives it: Part B providers and suppliers, hospices, home health agencies, RNHCIs; hospitals and SNFs for Part B items
When: Before the item or service, with time to decide. Never required in an emergency.
Length: Must be reproduced on a single page (letter or legal)
Get the form: ABN forms, English and Spanish, incl. large print (ZIP)

Who uses it

Physicians, practitioners, providers, and suppliers paid under Medicare Part B, including independent labs
Hospices and religious non-medical health care institutions paid under Part A
Home health agencies under Part A or Part B
Inpatient hospitals and SNFs, for Part B items and services only

Header

Notifier: Your name, address, and phone (and TTY when needed) at the top. It can be part of your logo.
Patient name: First and last name, with the middle initial if it is on the Medicare card. A misspelling does not void the notice if the patient recognizes the name.
Identification number: Optional internal number such as a medical record number. Never the Medicare number (MBI) or Social Security number.

Medicare exclusions and cost table

Item, test, service or care: The specific items you expect Medicare not to pay for. For repeated care, give the frequency or duration. Grouped supplies can be described as a group.
Reason Medicare may not pay: A plain-language reason for each item, for example that Medicare does not pay for the test this often.
Estimated cost: A good-faith estimate for each item. Routinely grouped items can share one estimate.

Options box

Option 1: The patient wants the service and wants Medicare billed for a decision. They may be asked to pay now and can appeal. Dually eligible patients are told to choose this option.
Option 2: The patient wants the service but does not want Medicare billed. No claim, no appeal rights.
Option 3: The patient does not want the service, owes nothing, and has no appeal rights.
Who checks the box: The patient or representative picks one option. A notifier who preselects an option voids the notice.

Additional information and signature

Additional information: Optional notes, such as other coverage. Non-participating suppliers strike the last Option 1 sentence and add CMS's unassigned claim statement here.
Signature and date: The patient or representative signs and dates after reviewing the notice. A representative writes "representative" after the signature.

Questions

When is an ABN required?

When Medicare is not likely to cover a specific item or service that is usually covered, before you provide it, so the patient can decide. It is never required in an emergency.

Can I use an ABN for a service Medicare never covers?

Yes, as a voluntary notice. CMS says the patient then does not need to choose an option or sign.

Does the patient get a copy?

The notifier gives a copy on request once the form is complete and signed, and keeps a copy on file.