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What is a Medicare advance beneficiary notice?

Your doctors and other health care providers must give you an advance beneficiary notice of noncoverage (ABN) if they believe that Medicare won’t pay for items, procedures or other services related to your medical care. This notice, given to you before you receive the care, lists what might not be covered, the reason why Medicare may not pay — and the estimated cost.

Because it comes from your provider, this notice, actually a form, isn’t an official denial from Medicare. But it’s a warning that if you decide to go ahead with a procedure, you’ll probably have to pay the full cost yourself. You must check one of three boxes on the form choosing if you:

  • Want the service and want the claim submitted to Medicare.
  • Want the service but don’t want the claim sent to Medicare.
  • Don’t want the service.
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This notice applies to recipients of original Medicare, which includes Medicare Part A and Part B, but not for private Medicare Advantage plans.

What should I do if I receive an advance beneficiary notice?

You’ll likely get one of these forms in person while you’re visiting your health care provider. But Medicare allows doctors, hospitals or medical equipment suppliers to deliver a copy of the form to a secure fax machine, send the form in the mail, talk to you on the telephone or use email to send you the form. They must give you the form far enough in advance so you have time to consider your options, although the government has not set a specified time period.

They must be able to verify that contact was made directly with you because federal health privacy laws restrict the sharing of certain health information and records.

Don’t ignore the form when you receive it. You’ll need to choose one of the options and sign the form. If you refuse to sign, you might not receive the services you’re expecting.

spinner image preview of Advance Beneficiary Notice of Non-Coverage form PDF
To read the form, click the image above.

With Option 1, the health care provider will submit a claim to Medicare, but you may have to make some payment in advance. If the federal agency denies the claim as expected, you’ll be responsible for the bill, but you do have a right to appeal a rejection to Medicare.

With Option 2, you stop any attempt for the provider to recoup money from Medicare. You acknowledge that you’ll have to pay for the services and can’t appeal.

With Option 3, you decide you don’t want the services, so you won’t receive them.

The first box on the form is the only one that gives you the right to appeal a denied claim. It also holds out the possibility that Medicare could cover what you want. You may also need to choose the first option if you need proof of a Medicare denial to trigger a payout from secondary insurance that has different coverage from Medicare, such as from an employer or retiree health insurance.

If your secondary insurance is a Medigap policy, it generally won’t pay for services that Medicare denies.

If the claim is submitted to Medicare, you’ll receive a Medicare summary notice, which is similar to an explanation of benefits for other health coverage, letting you know if the claim was approved or denied. This form includes instructions for appealing a claim denial.

Who provides an advance beneficiary notice?

Doctors and other health care providers, ambulance companies, equipment suppliers, home health agencies, hospice services and independent laboratories must provide the notice in situations when they expect Medicare payment will be denied. 

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You may receive an ABN before receiving a service, which could include:

  • A colorectal screening test or screening mammogram performed more frequently than Medicare’s preventive benefits cover. Medicare generally covers colonoscopies once every 10 years, or every two years if you're considered a high risk for colon cancer. It typically covers screening mammograms every 12 months for women starting at age 40.

  • Home health services when you don’t meet the definition of being homebound or requiring intermittent skilled nursing care.
  • Items and services considered “not reasonable and necessary” for the diagnosis or treatment of illness or injury.

Hospitals and skilled nursing facilities have a different advance beneficiary notice of noncoverage for services that Medicare Part A is unlikely to cover, such as services considered not medically necessary.

Keep in mind

If a provider knows that a service is unlikely to be covered but doesn’t give you an ABN beforehand, you may not be responsible for the cost of care. But that’s true only if Medicare denies the claim and you submit an appeal based on that assertion.

Relying on this possibility could be risky. So it’s important to check with your provider about all prescribed treatments, recommended procedures or desired services before you schedule them.

Yet providers aren’t required to give you an ABN for care and equipment that Medicare never covers, such as cosmetic surgery, hearing aids and routine eye care for most people.

Published November 22, 2022

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