Medicare providers and suppliers used this Advance Beneficiary Notice (ABN), Form CMS-R-131-G to warn Original Medicare patients when a service or item was likely not covered and the patient might have to pay out of pocket. The notice explains which services may be denied, why Medicare is expected not to pay, and the estimated cost, then asks the patient to choose whether to receive the service anyway or decline it. The patient signs and dates the form to show they understand they may be personally responsible for the bill if Medicare denies the claim.
This ABN form is used to:
✔️ Tell the patient what service may not be covered and why.
✔️ Show an estimated cost if Medicare does not pay.
✔️ Document the patient’s choice to receive or refuse the service and accept potential financial liability.
Note: The unified ABN Form CMS-R-131 has replaced this CMS-R-131-G version. Providers must use the current CMS-approved ABN with the latest expiration date for valid notices.
| Question | Answer |
|---|---|
| Form Name | Form No Cms R 131 G |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | abn form medicare 2020 pdf, abn form, printable medicare abn form 2020, printable abn forms |
