CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Advance Member Notice (AMN)

Form and acknowledgement that a member accepts financial responsibility for services that may be non-covered or not medically necessary; applies to BCBSND members and participating providers using this notice.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyAdvance Member Notice (AMN)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must inform the patient about the Advance Member Notice and certify that they have done so.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Advance Member Notice — Coverage and Responsibilities

Advance Member Notice criteria

Coverage stance and member/provider responsibilities as stated on the form:

Advance Member Notice: Completion of this form acknowledges that the member is fully responsible for all charges associated with the professional or institutional procedure/item/service requested because the procedure/item/service may not be medically necessary and/or is not a covered benefit. This notice is not required for the member to receive medically appropriate and necessary covered services.

Patient acknowledgement

Patient voluntarily signs acknowledging they are not under duress and understand that by signing they will be fully responsible for the total billed charge(s) for any listed procedure/item/service that is denied as non-covered by Blue Cross Blue Shield of North Dakota and will pay the provider as charged.
Patient understands it is their choice to have the services provided at a future date and time by this provider.

Provider certification

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyAdvance Member Notice (AMN)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must inform the patient about the Advance Member Notice and certify that they have done so.

SourceLink

On This Page

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Provider and Patient Acknowledgement Actions

Documentation Required

Provider certification of notice

As a participating Blue Cross Blue Shield of North Dakota provider, you must inform the patient about the Advance Member Notice and certify that you have done so. You also acknowledge that BCBSND medical policy, the BCBSND Participation Agreement, and any other BCBSND policies (including decisions on financial responsibility) supersede this Advance Member Notice.

Provider must complete and sign the Advance Member Notice form documenting that the patient was informed.
Provider certification acknowledges BCBSND medical policy and participation agreement supersede the notice and govern any determination of financial responsibility.

Denial Risk

Patient financial acknowledgement

The patient must acknowledge voluntarily that they understand and accept financial responsibility for billed charges if Blue Cross Blue Shield of North Dakota denies the listed procedure/item/service as non-covered. The acknowledgement must be signed before services are rendered and not under duress.

Patient acknowledges voluntary agreement to pay total billed charges for any procedure/item/service listed that is denied as non-covered by BCBSND.
Form fields to include: Patient name, Benefit Plan Number, Patient signature, Date, Procedure/Item/Service, and (Estimated) Billed Charge.

Terms and Governing Policies

Definition — Advance Member Notice

TermAdvance Member Notice

DefinitionA written notice acknowledging member responsibility for all charges if the procedure/item/service may not be medically necessary and/or is not a covered benefit

ScopeNot required for the member to receive medically appropriate and necessary covered services

PurposeObtains member acknowledgement of potential financial responsibility for specified services

Superseding policies and final authority

Governing policiesBCBSND medical policy, BCBSND Participation Agreement provisions, and any other policies promulgated by BCBSND

EffectSuch policies, including resulting decisions on financial responsibility, supersede the Advance Member Notice

Provider acknowledgementProviders certify they have informed the patient and acknowledge the superseding authority of BCBSND policies

OpenPayer

Advance Member Notice (AMN)

Advance Member Notice — Coverage and Responsibilities

Coding and Estimated Charges

Provider and Patient Acknowledgement Actions

Terms and Governing Policies