This article was updated on April 5, 2021, to reiterate that the form shall not be used.

Independence requires participating providers to comply with all Centers for Medicare & Medicaid Services (CMS) rules and regulations. CMS expressly prohibits providers from using the Advance Beneficiary Notice (ABN) or similar notices for Medicare Advantage members. 

Therefore, the Member Consent for Financial Responsibility for Unreferred/Non-covered Services form shall not be used for Medicare Advantage members.

CMS recommends that providers use the determination process established by the member’s health plan. If there is a question about whether a Medicare Advantage plan will cover an item or service, members or their provider can request prior authorization/precertification before services or items are provided. If the request is denied, written determinations provide denial reasons and set forth appeal rights. If a provider chooses to provide a service to a Medicare Advantage member without first ensuring the service is covered, the provider must hold the member harmless.

Learn more

If you have any questions regarding the authorization process, visit our dedicated web page for Authorizations on the NaviNet^® web portal (NaviNet Open). You may also call Provider Services at 1-800-ASK-BLUE (1-800-275-2583).

NaviNet^® is a registered trademark of NantHealth, an independent company.