Currentblue cross blue shield - tennesseePolicy N/A

Acknowledgement of Financial Responsibility Form

A patient/provider acknowledgement form used with BlueCross BlueShield of Tennessee commercial networks to document that a patient has been informed a service may not be covered and that the patient accepts financial responsibility if the insurer denies payment. It applies to a single procedure unless otherwise specified and expires six months from the form date.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyAcknowledgement of Financial Responsibility Form

Policy CodePolicy N/A

Change TypeAdministrative / informational

Effective Date

Next Review Date

Key ActionRetain an executed copy of the completed acknowledgement form on file as BlueCross BlueShield of Tennessee may request proof of documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this is an administrative acknowledgement form; no policy coverage updates provided.

1Procedure per form

6Form validity (months)

Acknowledgement of Financial Responsibility Form — Overview

This form documents that a patient has been informed that a proposed medical service may not be covered by BlueCross BlueShield of Tennessee and that the patient accepts financial responsibility if coverage is denied.

It is intended for use with BlueCross BlueShield of Tennessee commercial networks and applies to a single prescribed service/procedure unless otherwise specified.

Coverage Stance & Purpose

Coverage stance: Informational. The form documents patient notification that the service may not be covered and the patient’s acceptance of financial responsibility if BlueCross BlueShield of Tennessee denies payment, while also informing the patient of alternatives and the ability to request reconsideration or file a grievance.

Patient Acknowledgement Conditions

Patient acknowledges and accepts responsibility when the insurer may not cover the service:

ALL of the following

Patient has been informed that BlueCross BlueShield of Tennessee may not cover the referenced service(s) because the service is investigational, cosmetic, or not medically necessary/appropriate.
Provider explained alternative treatments available that may be covered by BlueCross.
Patient understands estimated out-of-pocket cost for the service(s).
Form includes a blank for estimated cost.
Patient accepts responsibility for all costs if service is not covered, including practitioner, facility, ancillary and related expenses.
Patient understands provider may request reconsideration and patient may request grievance/reconsideration before or after receiving the service(s).
Form applies to one procedure unless otherwise specified.
Form is no longer valid six months from the date on the form.

Required Provider Actions

Documentation Required

Retain executed form

Provider must retain an executed copy of this statement on file as BlueCross BlueShield of Tennessee may request proof of documentation.

BlueCross BlueShield of Tennessee may request proof of documentation

Documentation Required

Complete form per procedure

Complete the form for the specific prescribed service/procedure; the form applies to a single procedure unless otherwise specified.

Form applies to a single procedure unless otherwise specified
Form expires six months from date on form

Thresholds / Form Validity

Form Validity Period6 months from the date on the form