Medicare Appeals and the ABN in New York: What the Notice Means and How to Fight a Denial

What does ABN stand for, and what does it mean?

ABN is the Advance Beneficiary Notice of Non-coverage, the federal form CMS-R-131. CMS requires providers and suppliers to use it when Medicare is not likely to cover a specific item or service, so that you know before you receive it that you may have to pay. The notice must list the item or service, the reason Medicare may not pay, and a good-faith estimate of the cost.

The ABN belongs to Original Medicare. CMS’s own training says it applies only to the fee-for-service program, and Advantage plans use their own process: you or your doctor can ask the plan for a decision before the service. The notice is used by doctors and other Part B providers and suppliers, independent labs, home health agencies, hospices, and hospitals and nursing facilities for Part B items; hospitals and skilled nursing facilities use different notices for Part A care.

Three reasons appear on ABNs again and again, and CMS lists them as the common ones: Medicare does not pay for this test for your condition; Medicare does not pay for it this often; and Medicare does not pay for experimental or research use tests. “Too often” is the one most New Yorkers meet, on screening blood work and repeat imaging.

Which ABN option should you check?

The provider may not choose for you: CMS says pre-selecting an option invalidates the notice. If you refuse to choose, the provider writes that on the form and may decline to provide the service. If you want some items on the list and not others, the provider can use a second ABN.

Sentence at the front desk: “Before I sign, can you tell me which Medicare rule you think this fails, and is the cost estimate for the whole service? I’m choosing Option 1 so Medicare makes the decision.”

If you have QMB or Medicaid: the ABN works differently

People with both Medicare and Medicaid, or with QMB, have extra protection, and CMS writes it into the ABN instructions. Providers must tell dual-eligible patients to check Option 1, so the claim goes to Medicare, and they cannot bill you when the ABN is delivered. They must wait until both Medicare and Medicaid have decided the claim. After that, a provider may bill you only in two situations: you have QMB without full Medicaid, or you have full Medicaid and Medicaid denies the claim (or will not pay because the provider is not in Medicaid), subject to state limits.

Separately, the Medicare Rights Center’s 2026 training for New York counselors summarizes federal law: providers may not bill QMB members for Medicare deductibles, coinsurance or copays on Medicare-covered services, even if the provider does not take Medicaid, and Advantage members with QMB or Medicaid cannot be billed cost sharing for in-network care. If that happens, dispute it in writing and mention your QMB status. Medicare and Medicaid together.

When you will not get an ABN

Services Medicare never covers. Medicare’s appeals booklet says providers do not have to give an ABN for things Medicare generally does not cover, such as dental care, hearing aids, routine eye exams and routine foot care, although they may. You should expect to pay for those. Vision, dental and hearing with Medicare.

Emergencies. CMS states that ABNs are never required in emergency situations.

Medicare Advantage. There is no ABN. If you are unsure whether an Advantage plan will cover a service, ask the plan for a decision first; a denial in writing starts your appeal clock.

Hospital and nursing facility stays under Part A. Other notices apply: a Hospital Issued Notice of Non-coverage, the Skilled Nursing Facility ABN (Form CMS-10055), and the Important Message from Medicare about your discharge rights. Home health agencies also use a Home Health Change of Care Notice. Home health care rules.

How to appeal a denial in Original Medicare

The denial arrives on your Medicare Summary Notice, the statement Medicare mails at least every six months. The appeal path has five levels, and you can generally move to the next one if you disagree.

How to appeal a Medicare Advantage denial

A Medicare Advantage plan decides coverage itself, so the first appeal goes back to the plan.

Ask for a fast appeal if waiting could seriously harm your health; a doctor’s statement makes that request hard to refuse. Plans can extend some decisions by up to 14 days, but must tell you in writing. Drug denials under Part D follow a separate path, starting with a redetermination request within 65 days. When a drug is denied.

Fast appeals: leaving the hospital, home health or a nursing facility

These appeals go to an independent reviewer called the BFCC-QIO, and the deadlines are counted in hours, not months.

Hospital discharge. You should receive the Important Message from Medicare about Your Rights within two days of admission and again before discharge; ask for it if you did not. Follow its instructions no later than the day you are scheduled to be discharged. If you do, you can stay in the hospital while the reviewer decides and will not pay for that time, except normal coinsurance or deductibles. Miss it and you can still ask, but you may owe for days after the original discharge date.

Home health, skilled nursing, hospice or outpatient rehabilitation ending. You should get a Notice of Medicare Non-Coverage at least two days before covered services end. Ask for the fast appeal by noon the day before the end date on the notice. The reviewer’s phone number is on the notice, or call 1-800-MEDICARE.

Sentence for the call: “I received a notice that my Medicare-covered services end on [date]. I want a fast appeal. I am calling before the deadline on the notice.”

Who helps with a Medicare appeal for free

HIICAP, New York’s free Medicare counseling program, helps resolve insurance problems, and Medicare’s appeals booklet points beneficiaries to their SHIP for help with appeals: 1-800-701-0501. How to reach HIICAP in New York City. The Medicare Rights Center helpline is 800-333-4114. You can also name a representative, a relative or advocate, with an Appointment of Representative form so they can act for you. For appeals about Medicaid services, the route is a state fair hearing. Fair hearings · Appealing any insurance denial.