Providers (including independent laboratories), physicians, practitioners, and suppliers must use ABN Form CMS-R-131 for all situations where Medicare payment is expected to be denied. The current version of this form can be downloaded from the
CMS website.
The form is used to notify beneficiaries of Medicare reasons for Medicare denial and provide voluntary notification of financial liability.
Lab-specific key information (blanks A - D) can be preprinted.
Three commonly used reasons for noncoverage are:
- Medicare does not pay for this test for your condition.
- Medicare does not pay for this test as often as this (denied as too frequent).
- Medicare does not pay for experimental or research-use tests.
At least one reason for noncoverage must apply to each item or service listed in Blank (D). The same reason for noncoverage may be applied to multiple items in Blank (D).
