Providers (including independent laboratories), physicians, practitioners, and suppliers are required to 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.
There must be at least one reason applicable to each item or service listed in Blank (D). The same reason for noncoverage may be applied to multiple items in Blank (D).