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Provide Medicare Advantage HMO and PPO members notice of noncovered/excluded services and member payment responsibility 

August 29, 2013    


As a reminder, before providing noncovered/excluded services, providers must furnish Keystone 65 HMO or Personal Choice 65SM PPO members with written notice that the services are not covered and the members will be responsible for payment. Examples of noncovered/excluded services include, but are not limited to:
  • comfort and convenience items, such as a total electric hospital bed;
  • equipment inappropriate for home use, such as a standing frame system;
  • equipment that is not primarily medical in nature, such as some power wheelchair accessories (e.g., power seat elevation system, power standing feature, remote operation);
  • equipment with features of a medical nature that are not required by the individual’s condition, such as a water-circulating cold pad with pump;
  • other examples, including non-elastic binders and gradient compression stockings (HCPCS codes A6530; A6533-A6549).
This requirement for written notification of noncovered/excluded services and payment responsibility is contained in your Independence professional provider agreement, which states that in the event the Provider provides Non-covered or Excluded services to the Beneficiary, the Provider must inform the Beneficiary in advance in writing: (i) of the service(s) to be provided; (ii) that Independence [Blue Cross] will not pay for or be financially liable for said services; and (iii) that the Member will be financially liable for such services.

If the provider does not give written notice of noncovered/excluded services to the member, he or she is required to hold the member harmless.

Our Member Consent for Financial Responsibility for Unreferred/Non-covered Services form may be used when members request service(s) that are not covered under their Medicare benefits. This easy-to-use form, which is available on the Forms page of our website, requires the provider to list the type of service that is not covered. A copy of the form should be given to the member, and a copy should be made part of his or her medical record.

Please visit the Medical Policy portal for more information about noncovered/excluded services.





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