The Medicare ABN (CMS-R-131): when therapy may not be covered

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is the notice CMS says providers, practitioners, and suppliers give Original Medicare beneficiaries when Medicare payment is expected to be denied. Medicare.gov’s outpatient therapy fact sheet says a therapy provider can charge for services that are not medically necessary only if it gives this written notice first, and cannot give an ABN only because therapy expenses have reached a certain amount. The patient chooses one of three options on the form. This is separate from the good faith estimate for uninsured or self-pay patients.

Quoted from official pages checked November 10, 2026. Confirm current requirements, fees, and dates on those sites. This page is not legal advice and does not guarantee eligibility, certification, or licensure.

Sources read on November 10, 2026: CMS’s FFS ABN page (page last modified July 17, 2026), the ABN Form Instructions (PDF, OMB Approval Number 0938-0566), Medicare.gov’s fact sheet Medicare Coverage of Outpatient Occupational Therapy, Physical Therapy, and Speech-language Pathology Services (CMS Product No. 10988, October 2026), and Medicare.gov’s Your Medicare protections page. CMS points to the Medicare Claims Processing Manual, Chapter 30, for issuing guidelines; that chapter was not opened, and nothing is quoted from it. The cost-table examples on the form are not copied.

What the ABN is

CMS’s ABN page states: “Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied.” It continues: “The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.” It notes: “Skilled nursing facilities (SNFs) issue the ABN to transfer potential financial liability for items/services expected to be denied under Medicare Part B only.”

Medicare.gov’s protections page states: “Remember, an ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if a claim is submitted and Medicare denies payment.” Appeals are covered on Medicare appeals.

Outpatient therapy

Medicare.gov’s therapy fact sheet states: “If the therapy services you’re getting aren’t medically necessary, your therapy provider can only charge you for them if they give you a written notice before you get the services.” It states: “The ABN lets you choose whether or not you want the therapy services.” And: “Your therapy provider must tell you that your services aren’t medically necessary before giving you an ABN. They can’t give you an ABN only because your therapy expenses have reached a certain amount.” The fact sheet says its information “only applies if you have Original Medicare.”

The sources read for this page do not say that therapy always or never needs an ABN. Medical necessity and the plan of care are covered on Medicare therapy plans of care, and documentation on Medicare progress reports.

What the notifier must do

The form instructions state: “When Medicare is not likely to cover a specific item or service, health care providers and suppliers must use this ABN to let the patient know they may be financially liable before they get the items or services.” Notifiers must:

“Deliver the ABN to the patient or their representative before providing the items or services;”
“Review the ABN with the patient or their representative and answer any questions before it’s signed;”
“Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice;”
“Give a copy to the patient or representative, if requested, once all blanks are completed and the form is signed; and”
“Retain a copy of the completed, signed ABN on file.”

The instructions also state: “ABNs are never required in emergency situations.” And: “The ABN may also be used to notify patients of their financial liability for items or services that Medicare never covers.” Medicare.gov’s protections page states: “Medicare doesn’t require an ABN for items or services that Medicare never covers.” Both are quoted as read.

On the item list, the instructions state: “For repetitive or continuous non-covered care, specify the frequency and/or duration of the item or service.” On the estimated cost: “Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed”. The instructions also say the patient’s identifier is optional and that Medicare beneficiary identifiers “or Social Security numbers should not appear on the notice.” For the provider identifier used on claims, see the NPI page.

The three options

The instructions state: “The patient or their representative must check one of the boxes in the Options Box section.” Option 1 lets the patient get the service with a claim sent to Medicare; it reads in part: “I understand that if Medicare doesn’t pay, I’m responsible to pay, but I can appeal to Medicare by following the directions on the MSN.” Option 2 reads in part: “I understand I can’t appeal, since Medicare isn’t billed.” Option 3 reads: “I don’t want the item, test, service or care listed above. I understand I’m not responsible for payment and I can’t appeal to see if Medicare would pay.”

The instructions state: “Pre-selection of an option by the notifier invalidates the notice.” If the patient can’t or won’t choose, “the notice should be annotated ‘patient refused to choose an option.’” The instructions have separate rules for patients dually enrolled in Medicare and Medicaid; read them on the form.

What this page does not do

It copies no cost estimates, sample-form figures, or penalty amounts, and it does not decide whether any service is covered or whether an ABN is needed. It is not legal, billing, or compliance advice. Confirm current rules with the agency that publishes them, your employer, and your state board.