Advance Beneficiary Notice (ABN): Which Option Keeps Your Appeal Rights

Pick Option 1 if you want the service and want to keep your appeal rights: it is the only box that makes the provider bill Medicare, and Medicare's decision arrives on your Medicare Summary Notice, which you can appeal within 120 days. The provider can collect payment when you sign, at its own price rather than Medicare's rate, and refunds you, minus your deductible and coinsurance, if Medicare pays; if that refund line on the form is crossed out, Medicare pays you instead. Before you sign, check that the form names the exact service, states why a denial is expected and shows a cost estimate; after you sign, ask for a copy.

The ABN (Advance Beneficiary Notice of Non-coverage, Form CMS-R-131) states the provider's opinion, not an official Medicare decision.

When a provider has to give you an ABN

Doctors, labs, outpatient hospitals, home health agencies, hospices and equipment suppliers in Original Medicare must hand you an ABN before giving you something Medicare normally covers but is expected to deny in your case: care Medicare considers medically unnecessary for you, custodial care, experimental tests, or home health care when you are not homebound. CMS lists three common reasons:

Medicare covers this test only for certain conditions, not yours.
Medicare pays for this test only at set intervals, and you are due too soon.
Medicare treats this as an experimental or research-use test.

Providers must deliver the ABN early enough for you to decide. Emergencies need no ABN. For services Medicare generally doesn't cover, such as routine dental care, hearing aids and routine eye exams, a provider can hand you an ABN as a courtesy, and you neither pick a box nor sign.

What a valid ABN shows

The provider's name, address and phone number at the top.
Each item, test or service by name, and for repeated care, how frequently and for how long.
A plain-language reason for the expected denial of each item.
A good-faith cost estimate for each item, or for a bundled group such as a blood panel.
Three option boxes, all blank until you check one. A box the provider checked for you voids the notice.
Your signature and date, added after everything else is filled in.
Form CMS-R-131 printed at the bottom.

The three options

Option	You get the service	Medicare is billed	You can appeal	What you pay
1	Yes	Yes	Yes, after the Medicare Summary Notice	Payment can be collected now; refund if Medicare pays, minus deductible and coinsurance (crossed-out refund line: Medicare pays you)
2	Yes	No	No	You pay the provider
3	No	No	No	Nothing

Under Options 1 and 2 the charge can be the provider's usual fee, above the Medicare-approved amount. Pick Option 2 only if you want the service with no Medicare claim at all. Pick Option 3 if you decide against the service; you owe nothing.

What to do before you sign

Match each line in the item column to what your doctor ordered.
Check whether the refund sentence at the end of Option 1 is crossed out; if it is, ask for the full charge in writing.
Ask why they expect a denial. If the reason is a frequency limit, ask the date Medicare will cover it again and whether the test can wait until then.
Check one box yourself. If you physically cannot write, staff can mark your choice at your request and must note on the form that they did.
Sign, date and ask for a copy of the completed form.
For questions the office cannot answer, call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. Staff must answer your questions or send you to that number; a notice delivered while they refused is defective.

Where your situation splits

If the refund sentence at the end of Option 1 is crossed out, the provider has declined Medicare assignment: you pay its full charge, and if Medicare pays, the Medicare-approved amount comes to you, not a refund from the office, and can be less than you paid.
If you have a Medicare Advantage plan, the ABN belongs to Original Medicare only. Ask your plan for an organization determination before the service. The plan must answer within 14 days, 7 days for items that need prior authorization, or 72 hours for a fast decision; ask your doctor to request the fast one, because a doctor's request makes the plan expedite. Plans can add up to 14 days in some cases. If a plan provider sends you for covered care without getting that decision, you usually pay only the plan's normal cost sharing.
If you also have Medicaid or QMB, the provider tells you to check Option 1 and cannot bill you when you sign. After Medicare and Medicaid both decide the claim, the provider can charge you only if you have QMB without full Medicaid, or Medicaid denies the claim or the provider does not participate in Medicaid, within your state's limits. That liability reaches only a denied service: on anything Medicare covers, QMB members owe no deductibles, coinsurance or copays. See Medicare Savings Programs and Extra Help and having both Medicaid and Medicare.
If you refuse to sign, the provider writes the refusal on the form and can decline to give the service.

After a denial: appeal within 120 days

Medicare's decision shows on your Medicare Summary Notice, mailed at least every 6 months. Sign up in your Medicare.gov account and it comes by email for any month with a processed claim. Providers have 12 months to file; if the service never appears, ask the provider to file, then call 1-800-MEDICARE.

Your appeal, called a redetermination, goes to the Medicare Administrative Contractor that processed the claim.

Circle the denied service on a copy of the summary notice and write why you disagree, or fill out Form CMS-20027.
Add a note from the ordering doctor on why you need the service. Send all evidence at once: each later batch adds up to 14 days to the decision.
Mail it to the address on the notice's last page. The contractor must receive it within 120 days of the day you got the notice, which Medicare counts as 5 days after the notice date.
Expect a decision mailed within 60 days. A win shows on your next summary notice, and the provider then owes your refund.
If you lose, you have 180 days to ask for the second level, a reconsideration by an independent contractor.

If a serious illness, yours or a close family member's, made you miss 120 days, file anyway and explain: the contractor can accept that as good cause.

A short request reads:

Medicare Redetermination Request. Name: [your name]. Address: [your address]. Medicare number: [number]. Service appealed: [service] on [date] from [provider], denied on my Medicare Summary Notice dated [date]. I disagree because [my doctor ordered this for (diagnosis or symptom); the enclosed note explains why I need it now]. Enclosed: Medicare Summary Notice, doctor's note, signed ABN. Phone: [number]. Signature: [sign]. Date: [date].

When the provider pays instead of you

You owe nothing for a denied service when the provider needed an ABN and skipped it or gave a defective one, and the provider must refund anything you paid. A notice fails if the provider checked your box, had you sign it blank, listed no reason, handed it over during an emergency, or gave it after the care. An ABN given partway through repeated care covers only visits after you signed, and only the denial reason it names: a denial for a different reason is judged as if you had no ABN.

Your bill limit: the "Maximum You May Be Billed" column on your summary notice is the most the provider can charge you for that claim.
Refund deadline: a provider that owes you a refund has 30 days after it gets Medicare's claim decision (its remittance advice), or 15 days after a review decision if it requests review. Providers who knowingly skip it can face civil money penalties. Report a late refund to the contractor on your summary notice or to 1-800-MEDICARE.
Free help: your State Health Insurance Assistance Program (shiphelp.org) helps with claims and appeals at no cost.
Lawyer: worth a call when a large denied charge reaches the third level, an Administrative Law Judge hearing ($200 minimum in dispute in 2026).

Other Medicare notices that look like an ABN

SNF ABN (Form CMS-10055): a skilled nursing facility uses it when it expects Part A to stop covering your stay; you pay for the disputed care only after Medicare officially denies the claim, while your daily coinsurance continues.
Home health: the old HHABN is retired. Agencies use the regular ABN when they expect a Medicare denial, and the Home Health Change of Care Notice (Form CMS-10280) when they cut or stop services for their own reasons or because your doctor changed orders.
Notice of Medicare Non-Coverage (NOMNC): home health agencies, skilled nursing facilities and hospices give it at least 2 days before all your covered services end; call the BFCC-QIO on it by its deadline for a fast appeal.
Hospital: a Hospital-Issued Notice of Noncoverage (HINN) says the hospital expects Medicare to deny all or part of an inpatient stay.

Today

Check the ABN in front of you for a named service, a reason and a cost, and check Option 1 if you want the service and your appeal rights.
Watch your summary notice. If the claim is denied, mail your redetermination request well inside 120 days. The contractor's decision comes within 60 days.