Rules to Follow for Advance Beneficiary Notice of Noncoverage
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URGENT ABN COMPLIANCE ALERT: The version of Form CMS-R-131 currently in your files expires on January 31, 2026.
For all services rendered on or after February 1, 2026, providers MUST use the refreshed Advance Beneficiary Notice of Noncoverage (ABN) form with the updated expiration date. Using the old form after this date will result in an "invalid notice," making your practice financially liable for denied claims.
In that case, obtain a Centers for Medicare and Medicaid Services (CMS) Advance Beneficiary Notice of Noncoverage (ABN) BEFORE providing the specified procedure or service to the patient.
Below we’ll review when, why, and how you should use an ABN form.
What is the ABN?
The Centers for Medicare and Medicaid Services (CMS) ABN Form CMS-R-131is a standardized notice you must issue to a Medicare beneficiary before providing items or services that you believe Medicare will not pay for.
The ABN allows the beneficiary to make an informed decision: receive the service and accept financial responsibility, or refuse the service. Without a valid, signed ABN, if Medicare denies the claim, you cannot bill the patient.
How to Get the New 2026 ABN Form
Download: Visit the official CMS Beneficiary Notices Initiative (BNI) page.
Verify: Look at the bottom left corner of the form. The new version will have an expiration date later than 01/31/2026.
Using the ABN: A Compliance Checklist
Updating your template is only the first step. To ensure you get paid and remain compliant, you must also master the billing protocols and coverage rules associated with the ABN.
Follow these three steps to ensure your workflow is audit-proof.
Step 1: Use the Correct ABN Modifiers
When you submit a claim to Medicare that involves an ABN, you must use the correct modifiers to signal the status of the notice.
Modifier GA (Waiver of Liability Statement Issued)
When to use: Use this when you have issued a mandatory ABN for a service that is usually covered but is expected to be denied in this specific instance (e.g., lack of medical necessity).
What it means: You have a signed ABN on file. If Medicare denies the claim, you CAN bill the patient.
Modifier GZ (Item or Service Expected to Be Denied as Not Reasonable and Necessary)
When to use: Use this when you expect a denial for medical necessity, but you failed to issue an ABN (or the ABN is invalid/expired).
What it means: You do NOT have a valid ABN on file. You CANNOT bill the patient. The provider is financially liable.
Modifiers GX and GY (Statutory Exclusions)
Modifier GY: Used for items or services that are statutorily excluded from Medicare benefits.
Modifier GX: Used to report that a voluntary ABN was issued for a service that is statutorily excluded.
Combination: You can report GX and GY together to show that the service is excluded (GY) and you proactively notified the patient via a voluntary ABN (GX).
Step 2: Complying with QMB Billing Restrictions
Special care must be taken when treating patients in the Qualified Medicare Beneficiary (QMB) Program.
Federal law strictly prohibits providers from billing QMB individuals for Medicare Part A and Part B deductibles, coinsurance, or copayments. This is known as "improper billing" or "balance billing."
The Rule: You cannot issue an ABN to a QMB patient to shift liability for Medicare cost-sharing (deductibles/copays).
The Exception: You can issue an ABN to a QMB patient for items or services that are completely excluded from Medicare coverage. In this specific case, if the ABN is signed, the QMB patient can be charged.
Step 3: Do Medicare Advantage and Commercial Plans Require ABNs?
Medicare Advantage (Part C)
No. The CMS-R-131 ABN form is strictly for Original Medicare (Fee-for-Service) beneficiaries.
Medicare Advantage plans have their own specific notices, such as the Notice of Medicare Non-Coverage (NOMNC).
Check with the specific Part C plan for their required non-coverage forms.
Commercial Non-Medicare Plans
No. Do not use the Medicare ABN for private insurance (e.g., Aetna, BCBS, UHC).
Most commercial contracts require you to use their specific "Waiver of Liability" forms or follow their internal policies for non-covered services.
Common ABN Mistakes to Avoid in 2026
Telehealth Delivery: You cannot issue an ABN verbally over the phone. If providing telehealth services, you must send the ABN via secure email or patient portal and receive a signature before the session begins.
Using Expired Forms: As of Feb 1, 2026, any form with the "Exp. 01/31/2026" date is void.
Incomplete Cost Estimates: Leaving the "Estimated Cost" field blank can invalidate the entire notice.
Summary of Rules for 2026
To protect your revenue cycle this year, follow this checklist:
Update Your Forms: Ensure all ABNs used after Feb 1, 2026, show the new expiration date.
Estimate Costs: Always complete the "Estimated Cost" field on the ABN.
Check Modifiers: Use GA only when you have a signed ABN. Use GZ if you forgot.
Know Your Patient: Verify QMB status before attempting to collect any balance.
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