CMS Pub. 100-04, ch. 30, § 50.5

The ABN, Form CMS-R-131, is the OMB approved standard written notice. Failure to

use this notice as mandated could result in the notice being invalidated and/or the notifier

being held liable for the items or services in question.

The online replicable copies of the OMB approved ABN (CMS-R-131) and instructions

for notice completion are available on the CMS website at:

http://www.cms.gov/Medicare/Medicare-General- Information/BNI/ABN.html

A. Language Choice

The ABN is available in English and Spanish under a dedicated link on the web page

given above. Notifiers should choose the appropriate version of the ABN based on the

language the beneficiary best understands. Insertions must be in English when the

English language ABN is used. Similarly, when a Spanish language ABN is used, the

notifier should make insertions on the notice in Spanish, if applicable. In addition, verbal

assistance in other languages may be provided to assist beneficiaries in understanding the

document. However, the printed document is limited to the OMB-approved English and

Spanish versions. Notifiers should document any types of translation assistance that are

used in the “Additional Information” section of the notice.

B. Effective Versions

ABNs are effective as of the OMB approval or expiration date given at the bottom of

each notice. The routine approval is for 3-year use. Notifiers are expected to exclusively

use the current version of the ABN. CMS will allow a transition period for healthcare

providers and suppliers to switch from using expiring notices to newly approved notices.

C. General Notice Preparation Requirements

Number of Copies A minimum of two copies, including the

original, should be made so the

beneficiary and notifier each have one.

The notifier should retain the original

whenever possible.

Reproduction Notifiers may reproduce the ABN by

using self-carbonizing paper,

photocopying, digitized technology, or

another appropriate method. All

reproductions should conform to

applicable requirements.

Length and Size of Page The ABN form must not exceed one

page in length; however, attachments

are permitted for listing additional items

and services. If attachments are used,

they should allow for clear matching of

the items or services in question with

the reason and cost estimate

information. The ABN is designed as a

letter- sized form. If necessary, it may

be expanded to a legal-sized page.

Contrast of Paper and Print A visually high-contrast combination of

dark ink on a pale background should be

used. Do not use reversed print (i.e.

white print on black paper), or block-

shaded (highlighted) text.

Font Fonts as they appear in the ABN

downloaded from the CMS web site

should be used. In cases where changes

need to occur, notifiers should use

alternative fonts that are easily

readable, such as Arial, Arial Narrow,

Times New Roman, and Courier.

Any other changes to the font, such as

italics, embossing, bold, etc., should not

be used since they can make the ABN

more difficult to read. The font size

generally should be 12 point. Titles

should be 14-16 point, but insertions in

blanks of the ABN can be as small as 10

point if needed.

Information inserted by notifiers in the

blank spaces on the ABN may be typed

or legibly hand-written.

Customization Notifiers are permitted to do some

customization of ABNs, such as pre-

printing information in certain blanks to

promote efficiency and to ensure clarity

for beneficiaries. Notifiers may develop

multiple versions of the ABN specialized

to common treatment scenarios, using

the required language and general

formatting of the ABN.

Blanks (G)-(I) must be completed by the

beneficiary when the ABN is issued and

should not be pre-filled. Lettering of the

blanks (A-J) should be removed prior to

issuance of an ABN. If pre-printed

information is used to describe

items/services and/or common reasons

for non-coverage, the notifier must

clearly indicate on the ABN which

portions of the pre- printed information

are applicable to the beneficiary

Healthcare providers or suppliers who

pre-print a menu of items or services

may wish to list a cost estimate

alongside each item or service.

Modification The ABN may not be modified except as

specifically allowed by these

instructions.

Notifiers must exercise caution before

adding any customizations beyond these

guidelines, since changing ABNs too

much could result in invalid notice and

healthcare provider or supplier liability

for non-covered charges. Validity

judgments are generally made by

Medicare contractors, usually when

reviewing ABN-related claims; however,

any complaints received may be

investigated by contractors and/or CMS

central or regional offices.