Billing for Noncovered Services

Date Issued: 6/6/2012

To be consistent with CMS guidelines, we are reminding you about our policy for independent arrangements for the provision and payment of noncovered services for our members.

To render noncovered services to a patient, the provider should first make independent financial arrangements with the patient, acknowledging the patients' financial responsibility for this care, as follows:

  • The arrangements for the noncovered services are made in advance of the service.
  • The provider obtains a signed written document attesting to the specific noncovered service to be rendered to the patient.
  • In this document, the patient acknowledges that he or she is solely responsible for the payment of such noncovered service. Please note that CMS has determined generic waivers signed by patients are insufficient to hold them accountable for payment for a specific service.

A "covered service" is defined in the plan member's Evidence of Coverage, and it includes a service that is medically necessary and that a plan member is entitled to receive under the terms and conditions of his or her benefit program. In addition, a covered service is within the scope of the provider's practice, and the provider is authorized to render the service pursuant to the terms of their participation agreement with the plan.