Form CMS-R-131, Advance Beneficiary Notice of Noncoverage (ABN) Instructions
This form contains 9 fields organized into 4 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Additional Information | Text |
Please provide any additional information relevant to this notice.
|
| First Service Row | ||
| Item, Test, Service or Care | Text |
Please enter the specific item, test, service, or care for which Medicare may not pay.
|
| Reason Medicare May Not Pay | Text |
Please provide the reason why Medicare may not cover this item, test, service, or care.
|
| Estimated Cost | Number |
Please enter the estimated cost of the item, test, service, or care.
|
| Page 1 | ||
| Option 1: Want item, bill Medicare | Radiobutton |
Check this box if you want the item, test, service, or care listed and you want Medicare to be billed for an official decision on payment.
|
| Option 2: Want item, don't bill Medicare | Radiobutton |
Check this box if you want the item, test, service, or care listed but you do not want Medicare to be billed.
|
| Option 3: Don't want item | Radiobutton |
Check this box if you do not want the item, test, service, or care listed above.
|
| Signature and Date | ||
| Signature | Text |
Please provide your signature. Fill only if 'Option 1: Want item, bill Medicare', 'Option 2: Want item, don't bill Medicare' is 'Yes' for any.
Depends on:
Option 1: Want item, bill Medicare, Option 2: Want item, don't bill Medicare
|
| Date | Date |
Please provide the date. Fill only if 'Option 1: Want item, bill Medicare', 'Option 2: Want item, don't bill Medicare' is 'Yes' for any.
Depends on:
Option 1: Want item, bill Medicare, Option 2: Want item, don't bill Medicare
|