Form CMS-R-131, Advance Beneficiary Notice of Noncoverage (ABN) Completed Form Examples and Samples
Explore practical examples and samples of the Form CMS-R-131, Advance Beneficiary Notice of Noncoverage (ABN). Learn how to accurately complete this Medicare form with our detailed, step-by-step documentation guides.
Automated Processing of Form CMS-R-131 (ABN) from Clinical Consultation Notes
How this form was filled:
This example demonstrates how an AI agent extracts specific clinical data from an unstructured physician consultation summary to accurately complete the Form CMS-R-131 (ABN). By parsing the physician's narrative, the AI identifies the service, the medical necessity gap, the cost estimate, and the patient's selected payment preference, ensuring full compliance with Medicare documentation standards.
Source document used: Physician Clinical Consultation Notes
Patient Record ID: 99283-X. Date: March 14, 2026. Attending Physician: Dr. Sarah Jenkins. Regarding patient Robert Miller, we discussed the necessity of an additional comprehensive bone density scan (DEXA) for his hip, which exceeds the currently allowed Medicare frequency for his age group. I explained to Mr. Miller that while this test is clinically prudent given his recent minor fracture, it is highly likely that Medicare will deny payment as the frequency limits have been reached for this calendar year. I provided him with an estimate of $150.00 for the out-of-pocket expense should he decide to proceed today. We also touched upon his recent blood pressure medication adjustments and the need for a follow-up visit in three months. Mr. Miller understands the potential financial liability. After reviewing his options, he stated clearly, 'I want the scan done because I'm worried about the bone strength, but I want you to go ahead and bill Medicare first just in case they decide to cover it, and I'll deal with the paperwork later.' He signed the ABN at 2:30 PM today. Please ensure this is filed in the billing portal immediately to avoid any administrative delays.
Information used to fill out the document:
- Service: Comprehensive bone density scan (DEXA)
- Reason for Denial: Exceeds annual Medicare frequency limits
- Estimated Cost: $150.00
- Patient Name: Robert Miller
- Date Signed: March 14, 2026
- Selection: Option 1: I want the item, test, service or care and want Medicare billed
What this filled form sample shows:
- Contextual sentiment analysis to determine patient's choice from quotes
- Entity extraction of clinical services from narrative prose
- Automatic mapping of natural language dates to standard date formats
- Data normalization for financial cost figures
- Disambiguation of coverage reasons versus clinical notes
Form specifications and details:
| Form Name: | CMS-R-131 (ABN) |
| Document Type: | Advance Beneficiary Notice |
| Regulatory Agency: | Centers for Medicare & Medicaid Services |
| Use Case: | Medicare Part B service coverage notification |
| Categories: | beneficiary forms, CMS forms |
| Created: | May 25, 2026 09:55 PM |