EMS Signatures | Part 3: ABN Signatures

Next stop in our series on EMS signature issues is the Advance Beneficiary Notice of Non-Coverage (ABN). In case you’ve missed it, Part 1 addressed the Authorization of Benefits (AOB) patient signatures, and Part 2 discussed the Certificate of Medical Necessity (CMN), formerly known as the PCS.


What is the ABN?

The ABN is a document issued by CMS and provided by ambulance services to patients in situations where the transport is expected to be denied by Medicare. The ABN serves as notice to the patient that they will potentially be financially responsible for the service. The ABN must be provided to the patient prior to transport and with enough time for the patient to make an informed decision about whether they will accept or refuse the transport. To accomplish this, the form describes the reason the service may not be covered and an estimate of the cost. For more information on customizing and completing the form properly, review the CMS ABN Form Instructions.

The ABN is used in two different ways. In very limited circumstances it is required to be completed if the service is going to be billed to the patient. For the majority of situations, it will fall under its optional use and act as a courtesy to the patient so they’re aware of their financial responsibility before transport. Lastly, there are situations where the ABN is never allowed—specifically, in emergencies or other urgent situations. Let’s review each situation below.


When is it Required?

Situations where the ABN is required are very limited. You can review the regulations here (beginning in Section 50). To sum it up, the ABN is required when the transport is not “reasonable and necessary.” Those terms may look familiar separately, but do not confuse medical necessity or closest appropriate facility issues with required ABN situations. “Reasonable and necessary” means an ABN is required when the service at the destination can be more economically performed at the origin facility. For example, a transport from a SNF to a hospital for a blood draw or sutures, which could be performed at the SNF, would require an ABN. The key to identifying situations where an ABN is required is if you receive a transport request that makes you ask, “why is this patient being transported at all?” If that is the case, you should make a determination of whether an ABN is needed. Now, let’s look at optional uses.


When is it Optional?

The ABN is optional in non-emergency settings where your service believes the patient may have financial responsibility for the transport in situations other than the required use described above. We recommend our clients use the form in these situations because it keeps the patient and service on the same page regarding financial responsibility. However, your service is still permitted to bill the patient for these uncovered situations without an ABN. Examples of optional uses are:

  • Loaded mileage beyond the closest appropriate facility.
  • Lack of medical necessity for the transport.
  • Transport to a non-covered destination.
  • Transports for the convenience of the patient, their family, or a specific physician.
  • Transport by wheelchair or stretcher van.


When is it Not Permitted?

The ABN is not permitted in emergency situations or any other urgent transport situation where the patient is under duress. Prior to requesting the patient sign an ABN, your staff should always make a determination of whether the patient is under duress. Additionally, the ABN cannot be obtained retroactively. This is because it is used to provide notice for the patient to make an informed decision prior to transport. We recommend training your call intake staff on the situations where the ABN is required, optional, and not permitted. Correctly identifying these situations and obtaining the correct documentation can save your service from receiving improper payments and can help maintain good relationships with your patients.


How is an ABN Completed?

Now that we’ve identified when the ABN should and shouldn’t be used, let’s make sure we’re filling out the form correctly. The ABN is different from other forms, such as a CMN, because CMS created the ABN form and established detailed rules about how the form looks and how it is completed. If those rules are not followed, it can be deemed invalid. You can find the form here. We recommend that your service also review the instructions provided by CMS when creating the form and correctly filling it out.

Once the ABN has been properly completed with information in the instructions, including a good-faith estimate of the cost and the reason Medicare may not cover the transport, the patient must choose from one of the three option boxes for how they want their transport to be processed for payment. It is important to note that the patient must make this decision. If the patient refuses to decide, the crew may note that the patient refused to choose an option on the form. Also, if the patient is unable to check the box, the crew may do so and annotate that they marked the box at the patient’s request. We also recommend reviewing the instructions for the processing option boxes because there are some edits on the form required for QMB patients.

Next, the patient should sign the ABN. If the patient is mentally or physically unable to sign or otherwise has a known authorized representative, the representative may sign for the patient. If a representative signs on behalf of the patient, their signature should be clearly legible or noted in print. The representative must also note “representative” after their name in parenthesis. The date should also be written in the correct section. If the patient is unable to write the date themselves, the crew may write the date and annotate that they did so.

When the ABN is being used in an optional situation, CMS states that the patient should not choose a processing option box or sign the form. In any situation, the patient and the ambulance service should both keep a copy of the completed form (signed if applicable).

Again, if the ABN is not properly completed according to the instructions provided by CMS, it will be deemed invalid. So, we highly recommend establishing a detailed process for correctly obtaining the ABN.



The ABN can take some work to set up properly but is straightforward to administer. We recommend reviewing the  instruction form linked in this article and checking to see if your current process complies with CMS rules. We hope this post has been informative and that you contact us with any questions or concerns about this topic!