An ABN is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving certain items or services, notifying you:
An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare's decision.
You have the option to receive the items or services or to refuse them. In either case, you should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.
If you choose to receive the items or services:
If you choose NOT to receive the items or services:
Although Medicare may not pay for your items or services, there may be good reasons for your physician recommending them. You should notify your doctor of your refusal.
If you refuse to sign, one of two actions will take place:
When you sign an ABN and become liable for payment, you will have to pay for the item or service yourself, either out-of-pocket or by some other insurance coverage which you may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between you and Mayo Clinic. If this is a concern for you, you may want to ask for a cost estimate before you sign the ABN.
Certain items or services that are covered by Medicare are only covered up to a certain number of times within a specified amount of time. Examples of these "frequency limited" services include laboratory tests, some preventive screening tests and vaccinations. If you receive an ABN that gives a frequency limit as its reason, it means that Medicare will not pay if you exceed that limit on the service.
No. ABNs do not operate to reduce coverage at all. Only if and when Medicare does deny the claim, do you become liable for paying personally for the service or item. If Medicare decides to pay the claim, you have lost nothing by signing the ABN.
For more information about your Medicare coverage, please contact the Medicare Beneficiary Office: