Sign Up
Login
Try for Free
Login
An Advance Beneficiary Notice (ABN), Form CMS-R-131, is the standardized written notice that tells an Original Medicare patient, before a specific service, that Medicare is expected to deny payment, so the patient can choose whether to proceed and accept the cost. Practice and billing staff issue it when a case-specific denial is expected, such as psychotherapy beyond covered frequency. The completed notice is one page.
Front-desk, billing, and practice administration staff; the billing clinician remains responsible for a valid notice
The Original Medicare patient or their representative; the billing file; Medicare contractors on request
One page, about 100 to 200 words of practice-entered content · 5 to 10 minutes by hand (clinical team estimate)
Standardized CMS payer notice (compare: good faith estimate, financial policy)
Before an Original Medicare service the practice expects Medicare to deny in that specific case, such as psychotherapy beyond a covered frequency
The liability framework is law (section 1879, Social Security Act; 42 CFR 411.404); the form and its completion rules are Medicare payer policy
An Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, is the standardized notice a practice gives an Original Medicare patient before furnishing a service Medicare is expected to deny, so the patient can make an informed choice about receiving it and accepting the potential cost. The mechanism is older than the form: Congress created the limitation-on-liability framework in section 1879 of the Social Security Act in 1972, and the implementing regulation at 42 CFR 411.404 lets appropriate written notice establish that a patient knew Medicare would not pay. CMS unified today's single form in 2008, replacing the earlier general-use and laboratory versions. You will also hear it called an ABN, a Medicare waiver, or a waiver of liability, and the common expansion "Advanced Beneficiary Notice" is technically incorrect: the official adjective is "advance."
Two boundaries do the heavy lifting. First, the ABN belongs to Original Medicare fee-for-service only: it has no standing for Medicare Advantage enrollees, who sit under their plans' own determination and notice systems, and it is not a good faith estimate, which serves uninsured and self-pay clients under different law. Second, the official form is the requirement. CMS-R-131 is an approved standard notice (OMB control number 0938-0566, currently approved through March 2029), and Medicare's Claims Processing Manual warns that substituting another notice or materially altering the required language or formatting can invalidate the notice and leave the practice liable. Download the current form and its instructions from CMS; the template on this page is a preparation worksheet that mirrors the required elements so your entries are complete before anyone signs.
Any practice that treats Original Medicare patients and bills Medicare: solo therapists and psychologists, group practices, and clinic billing teams. Delivery is usually administrative, since CMS lets an employee or subcontractor present and explain the notice while the billing clinician stays responsible for its validity. The trigger is narrow: issue a mandatory ABN when you expect Medicare to deny an identified service in this particular case for a limitation-on-liability reason, most often frequency beyond coverage limits or an anticipated medical-necessity denial, not as a routine intake form for every Medicare patient. For uninsured and self-pay clients the parallel document is the good faith estimate; ordinary rates, cancellation charges, and payment terms for everyone belong in the practice financial policy.
The official CMS-R-131 is a one-page form with a fixed layout, and every element below maps to a field on it. Complete all of them before the patient signs: an incomplete or altered notice may be disregarded, which returns the cost to the practice.
Notifier and patient identification. The practice's name, address, and telephone number, and the patient's name. When the notifying and billing entities differ, both can be identified, with billing contact details made clear. Pitfall: the identification field is optional, and the Medicare Beneficiary Identifier and Social Security number should not appear on the ABN. Obsolete copied templates still circulate with a "Medicare #" field; use an internal chart number or nothing.
The specific service expected to be denied. Name the particular item or care, not a category. For a continuing course of psychotherapy, state the frequency and expected duration; for a partial denial, identify the excess component, such as the second session each week. Pitfall: broad entries like "all therapy sessions" identify no specific expected denial, and a blanket form signed at intake fails for the same reason.
The reason Medicare may not pay. A plain-language, case-specific reason for each listed service, for example that continued sessions at this frequency are not expected to meet Medicare's medical-necessity coverage rules. Pitfall: generic wording such as "Medicare may not pay" is insufficient because it states no basis; CMS's completion instructions require an applicable reason for every listed service.
The estimated cost. A good-faith estimate of what the patient would owe. It does not need to be exact, and CMS accepts an estimate that runs substantially higher than the final charge because it does not surprise the patient in the harmful direction. Pitfall: leaving the estimate blank violates the completion instructions; write a number, per session and for the course where relevant.
The option boxes. The patient or their representative picks one of three choices: receive the service and have Medicare billed, which preserves Medicare appeal rights; receive it with no Medicare claim, which gives up those rights for the transaction; or decline the service. Pitfall: staff or software preselecting an option invalidates the notice. The choice is the patient's, every time.
Signature, date, and delivery. The patient or representative signs and dates after reviewing the completed notice and before the service. Explain the form, answer questions, and give a copy; current CMS sources differ on whether a copy is owed routinely or on request, so handing one over every time and documenting it is the safe practice. Pitfall: no federal ABN rule requires the clinician or a supervisor to sign, and a signature obtained after the session cannot retroactively shift liability.
ADVANCE BENEFICIARY NOTICE (ABN) PREPARATION WORKSHEET Original Medicare FFS only. The official Form CMS-R-131 from CMS is the notice you must issue; this worksheet readies your entries so that form is valid before anyone signs. NOTIFIER AND PATIENT Practice name / address / phone: _______________________________ Patient name: ____________________ Internal ID (optional): ____ Never enter the Medicare number (MBI) or SSN on the notice. SERVICE EXPECTED TO BE DENIED (specific, never a category) Service or item: _______________________________________________ Course, if repetitive (frequency and duration): ________________ Excess component, for a partial denial: ________________________ REASON MEDICARE MAY NOT PAY (plain language, case-specific) ________________________________________________________________ ________________________________________________________________ ESTIMATED COST (good-faith figure; never leave blank) Per session: $__________ Course total, if stated: $___________ OPTIONS (the patient's choice; never preselect) [ ] Option 1: bill Medicare (Medicare appeal rights preserved) [ ] Option 2: no Medicare claim (no Medicare appeal) [ ] Option 3: patient declines the service Refusal to sign or choose: annotate on the notice and date it. SIGNATURE AND DELIVERY (before the service) Patient or representative signs and dates the official form. Explained by: ______________ Date: ________ Copy given: [ ] CLAIM AND FILE Modifier: [ ] GA (valid ABN on file) [ ] GZ (none obtained) Retain the signed notice 5 years (longer if state law requires) and produce it if the Medicare contractor requests it.
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: an Original Medicare psychotherapy patient continues twice-weekly sessions beyond the frequency the practice expects Medicare's coverage rules to support; the practice issues the official form before the next session. All details are fictional.
Advance Beneficiary Notice, prepared entries and file note. Cedar Grove Psychological Services · Patient: L.H. · Notice issued: 08/04/2026 · Instrument: official Form CMS-R-131
Service expected to be denied: Individual psychotherapy (90834) at twice-weekly frequency, 08/10/2026 through 10/30/2026. Medicare continues to be billed for one covered session each week; this notice covers the second weekly session only, the component the practice expects Medicare to deny.
Reason Medicare may not pay, as entered: Medicare pays for psychotherapy that meets its medical-necessity rules. For your condition, we expect Medicare to decide that a second session each week is more frequent than its coverage rules allow, so we expect it to deny the second weekly session.
Estimated cost, as entered: $145 per session, about $1,740 across the 12-week course if every second weekly session is denied. Entered as a good-faith figure before signature; the practice noted the final charge may come in lower.
Option and signature: L.H. read the completed notice, chose Option 1 (receive the sessions and have Medicare billed, keeping her Medicare appeal rights), marked the box herself, and signed and dated on 08/04/2026, before the 08/10/2026 session. No option was preselected.
Delivery and file note (R. Ortiz, billing coordinator): Notice reviewed with L.H. by phone on 08/03/2026 and in person on 08/04/2026; her questions about the appeal path were answered, and she took a completed copy home. Claims for the second weekly session will carry modifier GA. Signed original scanned to the billing file, retained five years, produced on contractor request. If Medicare pays a comparable claim during the course, the practice will issue a fresh notice rather than rely on this one.
This sample is fictional and for educational purposes. It does not describe a real patient or practice.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsSort every ABN habit into law, payer policy, or convention. The liability shift itself is law: section 1879 of the Social Security Act and 42 CFR 411.404 decide when a patient can be held to have known Medicare would not pay. How you get there is Medicare payer policy in the Claims Processing Manual, chapter 30: the approved form, the completion rules, the delivery and comprehension expectations, and retention of the signed notice for five years (longer where state law requires). Where the sources go quiet, convention fills the gap: no rule sets a minimum number of hours before the session, no rule prescribes mental-health wording for the reason field, and current CMS sources even differ on whether the patient's copy is owed routinely or on request, so the defensible practice is to deliver early, write plainly, and hand over a copy every time. A signed page is not the finish line either: reporting modifier GA only certifies that a valid notice exists, and a contractor can inspect the form, find it defective, and move the liability back to the practice. The notice also proves nothing about medical necessity; the claim still stands or falls on the clinical and billing record (see the billing note), and the signed ABN sits in the billing record a patient can obtain through a records request.
The form's scope is narrower than most practices assume. It is an Original Medicare fee-for-service instrument: Medicare Advantage plans run their own determination and notice processes, clinicians who have opted out of Medicare set financial terms through private contracts instead, and services Medicare never covers call for a voluntary notice the patient does not need to sign. Special protections override it too: Qualified Medicare Beneficiaries generally cannot be billed for Medicare-covered services regardless of a signed ABN, and CMS's instructions carry specific QMB directions. Keep the neighbors straight as well: the good faith estimate serves uninsured and self-pay clients (a Medicare enrollee generally does not qualify as uninsured for it), while routine charges such as missed-session fees are contract terms for your financial policy and are documented through no-show notes, not ABNs. This page is general documentation guidance, not legal advice. Consult your attorney or licensing board; state rules vary.
No CMS, OIG, or CERT publication reports an ABN-specific error rate for outpatient mental health, so treat any percentage you see quoted as borrowed from somewhere else. The scale and the consequences are documented, though. The Office of Management and Budget's 2026 approval package for Form CMS-R-131 models roughly 331.7 million notice responses a year across about 1.7 million respondents, burden estimates that work out to about seven minutes per notice, and Medicare's Claims Processing Manual spells out the audit mechanics: when a claim reports modifier GA, the contractor can request the form, judge its validity, and reassign liability to the practice if the notice fails. The BastionGPT Clinical Advisory Board sees the same errors most often in Advance Beneficiary Notice reviews:
BastionGPT is specifically trained, tuned, and clinically tested on Advance Beneficiary Notices.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
A mandatory ABN is tied to a specific expectation: Original Medicare normally covers the category of service, but you expect denial in this particular case for a limitation-on-liability reason, most often frequency beyond coverage limits or an anticipated medical-necessity denial. It is not required just because payment feels uncertain, and it is not an intake form: CMS requires a case-specific expected denial, and blanket forms signed by every Medicare patient establish no informed knowledge. For services Medicare never covers, a voluntary notice may be offered instead, and the patient does not need to pick an option or sign it.
Not necessarily. One notice can cover a defined repetitive course of psychotherapy when it states the service, the frequency, and the expected duration, and it stays effective while the course, the patient's condition, and the applicable coverage policy remain materially unchanged. No Medicare regulation requires renewal solely because twelve months have passed, although CMS permits renewal and a new notice is needed whenever the material facts change. One caution from the manual: if Medicare later pays for a comparable service, the earlier notice may no longer establish that the patient expected denial, so issue a fresh one before relying on it again.
The actual expected basis, in plain language, for each listed service: for example, that continued sessions at this frequency are not expected to meet Medicare's medical-necessity coverage rules. No regulation prescribes a mental-health-specific phrase, so do not hunt for magic wording, and do not promise that denial is certain. What fails is the generic version: "Medicare may not pay" states no basis at all, and CMS's completion instructions treat it as insufficient.
Yes. CMS permits electronic issuance and signature when the patient can review the complete form, ask questions, make an uncoerced choice, and sign before treatment, and the patient keeps the right to a paper copy. When in-person delivery is not possible, CMS recognizes alternatives such as a phone discussion combined with mail, fax, or secure electronic delivery. What does not work is a bare portal checkbox: dropping an unsigned form into a portal with no explanation fails the delivery standards even if a signature comes back.
No. Form CMS-R-131 is an Original Medicare fee-for-service instrument, and CMS limits it to that program. Medicare Advantage plans run their own organization-determination and notice processes, so contact the plan and use its coverage-determination or liability paperwork. A plan following some Medicare coverage rules does not make the fee-for-service form apply, and a signed CMS-R-131 gives no protection on a Medicare Advantage claim.
Annotate the refusal on the notice itself: that the options were explained, that the patient declined to choose or sign, and the date; a witness signature can be added but is not universally required. Then decide whether to furnish the service, weighing patient safety, potential harm, and liability. Furnishing it anyway means the practice may be unable to establish patient liability if Medicare denies, and the annotation does not guarantee the liability shifted; contractors still assess whether effective notice occurred.
Different patients, different law. The ABN is Medicare payer policy built on the Social Security Act's liability rules: it addresses an expected Medicare denial for an Original Medicare patient and preserves defined appeal choices. The good faith estimate comes from the No Surprises Act and serves uninsured and self-pay clients, with its own timing rules and dispute process; a Medicare enrollee generally does not count as uninsured for it. Neither replaces the other, and your financial policy handles ordinary fees for everyone.
Medicare's Claims Processing Manual says ABNs generally should be retained for five years from discharge or completion of delivery, with electronic retention acceptable, and a longer state records requirement governs when one applies. Keep the form retrievable: the practical trigger is a contractor request after a claim reports modifier GA, and when the notifying and billing entities differ, the billing entity should hold a copy. The signed notice is also part of the billing record a patient can ask for through a records request.
Yes, as preparation for the official form. Give it the service, frequency, duration, fee, and the coverage concern, and it drafts the case-specific reason wording, the estimate arithmetic, and a delivery note for your file, ready to transfer onto the current CMS-R-131 from CMS. It can also check a completed draft for the common invalidators and tell you whether GA, GZ, GX, or GY fits the claim. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.