CurrentAnthemPolicy N/A

Member (Patient) Responsibility Agreement - Waiver Form

Governs the use of a waiver form by contracting Anthem Blue Cross providers to document a member's advance agreement to be financially responsible for services or supplies determined by Anthem to be not medically necessary or non-covered. Affects Anthem Blue Cross members and contracting providers in the applicable jurisdiction.

Policy Summary

PayerAnthem

PolicyMember (Patient) Responsibility Agreement - Waiver Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must obtain a member's prior written agreement (waiver) before delivering any service or supply Anthem determines to be not medically necessary or non-covered and send the completed waiver with the initial claim for processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prior writtenwaiver execution timing

separate from admissionform placement

attach to initial claimclaims instruction

grievance & IMRmember rights

When a Member May Be Billed

Billing permission criteria with member waiver

Conditions under which a member may be billed despite Anthem's determination of non-coverage or lack of medical necessity:

Member has provided a written, signed waiver prior to delivery of the service or supply acknowledging financial responsibility for services Anthem determined to be not Medically Necessary or non-covered.

Waiver form (or another writing documenting the same contents) must be executed prior to the delivery of any non-Medically Necessary or non-covered service or supply and must be separate from any patient payment responsibility information in the hospital admission form.

Waiver must specify the service(s)/supply(ies), approximate cost, and the Member's responsibility; Member acknowledges understanding of appeal rights including filing a grievance with Anthem or the Department of Managed Health Care and the right to request Independent Medical Review as described in the Evidence of Coverage.

Provider must send a completed copy of the waiver with the initial claim to the claims address on the Member identification card for appropriate claims processing.

Policy Summary

PayerAnthem

PolicyMember (Patient) Responsibility Agreement - Waiver Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements for Waiver and Claims

Documentation Required

Obtain prior written waiver and submit with initial claim

Before delivering any service or supply that Anthem determines to be not medically necessary or non-covered, obtain the member's prior written, signed waiver documenting their agreement to be financially responsible; the waiver must be executed prior to delivery and must be separate from any hospital admission payment information. Send a completed copy of the waiver with the initial claim to the claims address on the member identification card for appropriate claims processing.

Waiver must be executed prior to delivery of the non‑Medically Necessary or non‑covered service or supply.
Waiver must be separate from any patient payment responsibility information in the hospital admission form.
Provider must send a completed copy of the waiver with the initial claim to the claims address on the member identification card.

Key Terms

Not Medically Necessary / non-covered

DefinitionService or supply determined by Anthem Blue Cross to be not Medically Necessary or otherwise not a covered benefit or excluded under the member's coverage.

Member financial responsibilityContracting providers are prohibited from charging members for such services unless the member specifically agrees in advance in writing (executed prior to delivery).

Form requirementThe waiver form (or equivalent writing documenting the same) must be separate from any patient payment responsibility information in the hospital admission form to be valid.

Execution timingTo be effective and valid, the waiver must be executed prior to the delivery of the non-Medically Necessary or non-covered service or supply.

Claim documentationProvider must send a completed copy of the waiver with the initial claim for processing (see provider actions).

Independent Medical Review (IMR)

IMR rightMember may request Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC) as described in their Benefit Agreement or Evidence of Coverage (EOC).

Appeal channelsMember may file a grievance or appeal with Anthem Blue Cross or the DMHC pursuant to the grievance and appeals procedures described in the Benefit Agreement or EOC.

ScopeIMR and grievance rights apply to determinations that a service or supply is not Medically Necessary or non-covered.