CurrentBlue Cross Blue Shield - MainePolicy N/A

Member (Patient) Responsibility Agreement - Waiver Form

Governs use of a waiver form documenting a member's advance agreement to pay for services Anthem Blue Cross deems not medically necessary or non-covered; affects contracting Anthem Blue Cross providers and affected members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMember (Patient) Responsibility Agreement - Waiver Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse the waiver form to document the member's advance written agreement to be financially responsible and execute it prior to delivery; send completed waiver with the initial claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required waiver form to collect member financial responsibility

prior to servicewaiver must be executed before delivery of non-covered service

send with initial claimprovider must submit completed waiver with initial claim

appeal rights notedmember may appeal determinations and seek DMHC independent review

When a Member May Be Billed

Member financial responsibility criteria

Conditions under which a member may be billed directly by a contracting provider:

Member has specifically agreed in advance in writing to be financially responsible for services or supplies Anthem Blue Cross determines to be not Medically Necessary or otherwise not a covered benefit or excluded under coverage.

Waiver (this form or another writing documenting its contents) must be executed prior to delivery of the service or supply and must be separate from hospital admission payment information.

Provider must send the completed waiver form with the initial claim to the claims address on the member identification card; execution of the waiver does not change contracted rates.

Member retains appeal rights: the member and/or provider may file a grievance or appeal with Anthem Blue Cross and may seek Independent Medical Review through the DMHC as described in the member's Evidence of Coverage.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMember (Patient) Responsibility Agreement - Waiver Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse the waiver form to document the member's advance written agreement to be financially responsible and execute it prior to delivery; send completed waiver with the initial claim.

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.

Form Itemization and Code Listing

Not specifiedmixed

No codes listed

Member financial responsibility items — form lists description, approximate cost, and member responsibility for each service/supply

Form purposeLists each service or supply, an approximate cost, and the member's financial responsibility for that item.

Fields capturedDescription of service and/or supply; Approximate cost of service and/or supply; Member's (Patient's) Responsibility.

Placement requirementWaiver form or equivalent writing must be separate from hospital admission payment information.

Billing noteItems listed may not appear on the member's EOB but the member remains financially responsible per the signed waiver.

SignatureMember (Patient) signature required to acknowledge financial responsibility for listed items.

Required Provider Actions and Billing Instructions

Documentation Required

Waiver execution requirement

Contracting Blue Cross Blue Shield - Maine health care professionals/facilities ('Providers') are prohibited from charging Members for any service or supply that BCBS Maine determines to be not medically necessary or non-covered, unless the Member specifically agrees in advance to be financially responsible for such service or supply. To document that agreement, Providers must obtain a signed Member (Patient) Responsibility Agreement - Waiver Form (or another written document that contains the same information) that is executed in accordance with the timeframe below. The waiver must be separate from any hospital admission patient payment responsibility information and must be executed prior to delivery of any non-medically necessary or non-covered service or supply to be valid and effective.

Waiver must be executed prior to delivery of the non-Medically Necessary or non-covered service or supply.
Waiver must be separate from hospital admission patient payment responsibility information.
Waiver may be the Member (Patient) Responsibility Agreement - Waiver Form or another writing documenting the same contents.

Billing Rule

Claims submission of waiver

Provider, please send a completed copy of the signed waiver form with the initial claim to the claims address shown on the Member (Patient)'s identification card for appropriate claims processing. The completed waiver submitted with the claim documents the Member's prior agreement to accept financial responsibility and must accompany the initial claim submission. Submission of a waiver does not represent a renegotiation of any previously negotiated rate between Provider and Blue Cross Blue Shield - Maine.

Include the completed waiver form with the initial claim.
Send to the claims address on the Member's identification card.
Submission of the waiver does not alter contracted rates between Provider and BCBS Maine.

Term Definitions

Not Medically Necessary

DefinitionServices or supplies Anthem Blue Cross determines to be not Medically Necessary.

Billing restrictionContracting providers are prohibited from charging members for services determined to be not Medically Necessary unless the member specifically agrees in advance in writing.

Waiver timingWaiver must be executed prior to delivery of the non-Medically Necessary service or supply.

Appeal rightsMember may appeal determinations and pursue Independent Medical Review through the DMHC as described in their EOC.

Non-covered / Excluded

DefinitionServices or supplies that are otherwise not a covered benefit or excluded under the member's coverage.

Member agreementMember must specifically agree in advance in writing to be financially responsible for non-covered or excluded items for a provider to charge them.

Form separationWaiver documenting agreement must be separate from hospital admission payment information.

Claims submissionProvider must send the completed waiver with the initial claim to the claims address on the member ID card.