Limited Patient Waiver
Customize your policy alerts
Sign up for all blue cross blue shield - kansas policy alerts
Know when blue cross blue shield - kansas releases new policies or updates existing guidance.
Monitor payer policy activity
This document is a patient waiver form informing members that specified services or items are not covered by Blue Cross and Blue Shield of Kansas and obtaining the patient's acknowledgment of personal financial responsibility and choices about billing.
No material clinical or coverage changes in this revision.
Coverage Acknowledgement & Election
Coverage acknowledgement and patient election
Covered when ALL of the following are acknowledged and the patient makes an election:
Use the Limited Patient Waiver form to document notice to the patient.
Reason(s) the service may be considered not covered (ONE or more):
- Patient-requested services
- Utilization denials
- Experimental or investigational
- Not medically necessary
- Deluxe features (allowance for standard item(s) will be applied to deluxe item(s))
Patient billing election (choose ONE):
- Option 1: Patient requests the provider bill BCBSKS so the carrier may make a coverage determination (provider may bill insurance).
Provider may bill insurance only if patient selects Option 1 and must document the discussion in the patient record.
- Option 2: Patient elects that the provider not bill BCBSKS and accepts personal financial responsibility without appeal rights (provider must not bill insurance).
If patient selects Option 2, the patient forfeits appeal rights per policy.
Witness must personally observe the signature as indicated on the form.
Uncovered Service Identifier (Code)
| Nomenclature/Procedure Code/Appliance | Placeholder field for the specific service/item not covered |
Documentation, Billing Options, and Provider Responsibilities
Document patient discussion and billing option selection
The provider must document in the patient record the discussion with the patient regarding the listed service(s) and record which billing option the patient selected. Options are presented on the form and the provider should check the selected box and obtain witness/date as indicated.
- Document the discussion in the patient record.
- Record the patient’s selected Option (check the appropriate box on the form).
- Obtain witness signature and date on the form.
If patient elects Option 2, do not bill insurance; patient forfeits appeal rights
If the patient selects Option 2, the provider must not bill the patient’s insurance and the patient accepts responsibility for the charge and forfeits appeal rights.
- Do not submit a claim to the carrier if Option 2 is selected.
- Inform patient that by choosing Option 2 they are responsible for the charge and have no appeal rights if the claim is not processed through insurance.
Key Definitions and Patient Options
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.