Advance Member Notice (AMN)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - North Dakota policy alerts
Know when Blue Cross Blue Shield - North Dakota releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
Advance Member Notice — Coverage and Responsibilities
Advance Member Notice criteria
Coverage stance and member/provider responsibilities as stated on the form:
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
- As a participating Blue Cross Blue Shield of North Dakota provider, the provider certifies they have informed the patient regarding the Advance Member Notice.
- Provider acknowledges that BCBSND medical policy, BCBSND Participation Agreement provisions, and any other policies promulgated by BCBSND, including any resulting decisions on financial responsibility, supersede this Advance Member Notice.
Coding and Estimated Charges
| No codes listed |
Provider and Patient Acknowledgement Actions
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.
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
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.