What Is an ABN (Advance Beneficiary Notice)? Definition for Clinics
An ABN, form CMS-R-131, is a written notice a provider gives an Original Medicare patient before a service Medicare is expected to deny, so the patient can accept financial responsibility for it.
The Advance Beneficiary Notice of Noncoverage (ABN) is the Medicare form you hand a patient before a service you expect Medicare not to pay for. CMS says it is issued "in order to transfer potential financial liability to the Medicare beneficiary" (CMS). The textbook case is chiropractic maintenance care. The Illinois Chiropractic Society quotes CMS that acute, chronic and maintenance adjustments are all covered services, while maintenance care is not reimbursable (ILCS). An ABN signed before that maintenance visit lets the clinic collect from the patient.
When do you need to give an ABN?
You give an ABN before a service when you expect Medicare to deny payment for it. CMS describes the form, CMS-R-131, as issued by providers, physicians, practitioners and suppliers to Original Medicare beneficiaries "where Medicare payment is expected to be denied," and points to Chapter 30, Section 50 of the Medicare Claims Processing Manual for the detailed rules (CMS). In a PT clinic that might be care past the point where it is medically necessary. In a chiropractic office it is usually maintenance adjustments. The timing matters: the notice comes before the service, so the patient can decide with the price in front of them.
What do the options on an ABN mean?
The ABN gives the patient options, and the one they pick decides whether a claim gets filed. Per the Illinois Chiropractic Society's summary of the CMS manual, if the patient picks Option 1 the clinic is still required to submit a claim to Medicare, and if they pick Option 2 the clinic cannot submit one (ILCS). The patient has to make the choice personally. Train the front desk to explain the form in plain words and then stop talking, because a patient who feels pushed is a patient who complains later.
Does an ABN let a PT or chiropractor run a cash practice with Medicare patients?
No, not on its own. CMS lists physical therapists and chiropractors as not eligible to opt out of Medicare (CMS), and covered services still fall under mandatory claims submission. The ABN handles specific expected denials; it is not a way to turn every Medicare visit into cash. Read Medicare and cash-based physical therapy or, for chiropractors, should chiropractors drop insurance before you build a plan around it.
This is general information, not legal or billing advice; check your state board and a healthcare attorney before you change how you bill.
Questions owners ask
Can I use an ABN to see Medicare patients for cash?
Not as a blanket workaround. The ABN is for specific services you expect Medicare to deny, it is given before the service, and depending on the option the patient picks you may still have to file a claim.
Does the ABN apply to Medicare Advantage patients?
CMS describes the ABN as a notice for Original Medicare (fee-for-service) beneficiaries. Medicare Advantage plans have their own processes, so check with the plan.
Who picks the option on the ABN?
The patient does. The Illinois Chiropractic Society's summary of CMS rules stresses that the beneficiary must select the option personally, not the front desk.