As a reminder, before providing noncovered/excluded services, providers must furnish Keystone 65 HMO or Personal Choice 65^SM 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.