Advance Beneficiary Notice of Non-coverage Form

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Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for PT Services below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the PT Services below.

D. Physical Therapy Services	E. Reason Medicare May Not Pay	F. Estimated Cost
PT Services	• Yearly CAP has been reached • Services exceed $2410, so will be denied • No Medicare allowed Rx on file • The diagnosis/treatment techniques used are not covered by Medicare. • You have instructed us to bill another insurance company for these services. • Therapist believes this treatment is not medically necessary	Treatment, evaluation, reevaluation: $150 per session

What You Need to Do Now

Read this notice to make an informed decision about your care.
Ask any questions you may have before signing.
Choose one of the options below.

Note: If you choose Option 1 or 2, we may help you to use any other insurance you have, but Medicare cannot require us to do this.

G. Select the opiton you desire (Required):

OPTION 1: I want the PT Services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment (MSN). If Medicare doesn’t pay, I’m responsible but can appeal. If Medicare pays, you will refund payments I made, less co-pays/deductibles.

OPTION 2: I want the PT Services listed above, but do NOT bill Medicare. You may ask to be paid now; I understand I cannot appeal.

OPTION 3: I don’t want the PT Services listed above. I understand I’m not responsible for payment and cannot appeal.

H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (TTY: 1-877-486-2048). Signing below means you have received and understand this notice. You may request a copy.

You have the right to get Medicare information in an accessible format—large print, Braille, or audio—and to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.

According to the Paperwork Reduction Act of 1995, no one must respond unless it displays a valid OMB control number. The valid OMB control number is 0938-0566. The time required to complete this collection is estimated at 7 minutes, including review, data gathering, and submission. Comments on accuracy or improvements: write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, MD 21244-1850.

Form CMS-R-131 (Exp.01/31/2026) Form Approved OMB No. 0938-0566

You will receive a copy of this document via email. For your information, here is the document format you will receive filled out, click here.

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