Currentblue cross blue shield - tennesseePolicy N/A

Acknowledgement of Financial Responsibility for the Cost of Services

A patient/provider acknowledgement form used with BlueCross Commercial Networks where the patient accepts financial responsibility if BlueCross BlueShield of Tennessee does not cover a specified service (investigational, cosmetic, or not medically necessary). The form documents patient understanding of potential costs, alternatives, and appeal/reconsideration rights and must be retained by the provider for six months.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyAcknowledgement of Financial Responsibility for the Cost of Services

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProvider must retain an executed copy of the signed acknowledgement form on file as BlueCross BlueShield of Tennessee may request proof of documentation.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Procedure per form

6 monthsForm validity period

Policy overview

This is a provider/patient acknowledgement form used in BlueCross Commercial Networks to document that a member understands the financial risk if a service is not covered by BlueCross BlueShield of Tennessee. It records that the provider explained the service may be investigational, cosmetic, or not medically necessary/appropriate, that alternatives and appeal/reconsideration rights were discussed, and that the patient accepts financial responsibility if BlueCross does not pay. Status: CURRENT; Subject: Acknowledgement of Financial Responsibility for the Cost of Services.

PolicyAcknowledgement of Financial Responsibility for the Cost of Services

PayerBlueCross BlueShield of Tennessee

Policy NumberN/A

StatusCURRENT

Scope SummaryA patient/provider acknowledgement form used with BlueCross Commercial Networks where the patient accepts financial responsibility if BlueCross BlueShield of Tennessee does not cover a specified service (investigational, cosmetic, or not medically necessary). The form documents patient understanding of potential costs, alternatives, and appeal/reconsideration rights and must be retained by the provider for six months.

Procedure per form1

Form validity period6 months

Patient acknowledgement conditions

Patient Acknowledgement Conditions

Patient acknowledges and agrees to the following statements:

ALL of the following

Patient has been informed that the insurer/administrator, BlueCross BlueShield of Tennessee, may not cover the prescribed service/procedure.
Provider explained that the service may not be covered because it is investigational, cosmetic, or not medically necessary/appropriate.
Provider explained alternative treatments that may be covered by BlueCross.
Patient understands the estimated out-of-pocket cost for the service and accepts financial responsibility if BlueCross does not pay for the service.
Patient understands that financial responsibility includes practitioner, facility, ancillary and other related charges.
Patient understands they or the provider may request reconsideration of BlueCross's coverage decision per the member grievance section, before or after receiving the service.
The acknowledgement applies to a single procedure unless otherwise specified.
The form is invalid six months from the date on the form.

Required provider actions & risks

Documentation Required

Retain executed acknowledgement

Provider must retain an executed copy of the signed acknowledgement form on file. BlueCross BlueShield of Tennessee may request proof of this documentation.

Keep signed copy of the acknowledgement form in the patient's record.
Be prepared to produce the executed form if BlueCross requests proof of documentation.

Documentation Required

Form validity period

The acknowledgement form is no longer valid six months from the date on the form. If the service occurs after that six‑month period, providers should obtain a new signed acknowledgement from the patient.

Confirm form date and verify it is within six months before providing the service.
If more than six months have passed, obtain a new acknowledgement prior to the procedure.

Denial Risk

Patient financial responsibility if not covered

If BlueCross does not cover the referenced service(s), the patient accepts responsibility for all associated costs. This includes practitioner charges, facility charges, ancillary charges, and any other related expenses.

Discuss estimated out-of-pocket cost with the patient before the service.
Document the patient's acceptance of financial responsibility on the acknowledgement form.

Scope and applicability

Applies to members in BlueCross Commercial Networks and documents acceptance of financial responsibility if BlueCross BlueShield of Tennessee does not cover a specified service (for example investigational, cosmetic, or not medically necessary). The acknowledgement generally applies to a single procedure unless otherwise specified, and providers must retain an executed copy of the signed form on file; the form is not valid six months from the date on the form.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyAcknowledgement of Financial Responsibility for the Cost of Services

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProvider must retain an executed copy of the signed acknowledgement form on file as BlueCross BlueShield of Tennessee may request proof of documentation.

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Acknowledgement of Financial Responsibility for the Cost of Services

Policy overview

Patient acknowledgement conditions

Required provider actions & risks

Defined terms

Scope and applicability

Revision history