CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Acknowledgement of Financial Responsibility for Dental Services

A patient-facing acknowledgement form documenting that the member understands potential noncoverage for specified dental services (investigational, cosmetic, or not medically necessary) and accepts financial responsibility if the insurer denies payment. Used with BCBST Dental Preferred members and their dentists.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyAcknowledgement of Financial Responsibility for Dental Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the acknowledgement form documenting the prescribed service, alternatives discussed, and the approximate cost; obtain patient signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsform validity period

1units covered by form

approximate costcost field

Coverage Criteria & Form Conditions

Acknowledgement conditions

The form documents patient acknowledgement — it does not alter coverage determinations by the insurer.

Patient acknowledgement conditions: Patient is informed that the dental service(s) may be investigational, cosmetic, not a covered service, or not medically necessary/medically appropriate as defined in the member's dental plan; alternatives (if any) were discussed; and the patient acknowledges potential financial responsibility if BlueCross BlueShield of Tennessee determines the service is investigational, cosmetic, not a covered service, or not medically necessary/appropriate.

This is an acknowledgement form only; coverage determinations remain with the insurer.

Reconsideration and appeals: Dentist may request BlueCross BlueShield of Tennessee to reconsider a determination by presenting evidence that the referenced dental service(s) is not investigational, is a covered service, or is medically necessary/appropriate; the member may also request reconsideration per the Member grievance section of the dental health care benefits plan.

Reconsideration does not imply guaranteed coverage.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyAcknowledgement of Financial Responsibility for Dental Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the acknowledgement form documenting the prescribed service, alternatives discussed, and the approximate cost; obtain patient signature.

SourceLink

On This Page

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Provider Responsibilities & Appeals

Denial Risk

Patient Financial Responsibility & Documentation

BlueCross BlueShield of Tennessee may determine that a requested dental service is investigational, cosmetic, not a covered service, or not medically necessary/appropriate under the member's dental benefits. If the payer makes one of these determinations the service may be denied and the patient could be financially responsible for all charges (practitioner, facility, ancillary, and related expenses).

Identify the prescribed service in writing on the Acknowledgement of Financial Responsibility form.
Document alternative treatments discussed with the patient and note if any alternatives may be covered by BCBS of Tennessee.
Record the approximate potential cost of the service on the form.
Form is valid for one unit of the prescribed dental service unless otherwise noted.

Note

Reconsideration / Appeals Available

The dentist or patient has the right to request reconsideration or file a grievance. The provider may present clinical evidence to support that the service is not investigational, is a covered service, or is medically necessary/appropriate. Members may request reconsideration as described in their member grievance process, either before or after receiving the service.

Provider may submit supporting evidence for reconsideration.
Member may pursue the grievance/reconsideration process per the dental benefits plan.

Documentation Required

Required Form & Documentation

Providers must complete the BlueCross BlueShield of Tennessee Acknowledgement of Financial Responsibility form when applicable. The form must: identify the prescribed service, document alternatives discussed, and include an approximate cost estimate for the service.

Use the standard BCBST Acknowledgement of Financial Responsibility for Dental Services (for BCBST Dental Preferred).
Ensure the prescribed service and alternatives are explicitly described on the form.
Include an approximate cost amount and note that the member may be financially responsible if the service is denied.

Denial Risk

Triggers for Denial & Patient Liability

If the service is determined to be investigational, cosmetic, not a covered benefit, or not medically necessary/appropriate, the claim may be denied and the patient will be responsible for payment. This risk should be communicated to the patient and documented on the Acknowledgement form prior to providing the service.

Denial triggers: Investigational, Cosmetic, Not Covered, Not Medically Necessary/Appropriate.
Communicate potential patient financial responsibility prior to service.
Document acknowledgement of financial responsibility on the required form.

Key Definitions

Medically Necessary / Medically Appropriate

DefinitionMedically Necessary / Medically Appropriate: as defined in the member's dental health care benefits plan from BlueCross BlueShield of Tennessee (refer to the plan for the full definition).

Implication for coverageIf BlueCross BlueShield of Tennessee determines the service is not Medically Necessary or Medically Appropriate, the service will be excluded from coverage and the patient will be responsible for costs.

Reconsideration rightDentist or member may request reconsideration per the Member grievance section of the member's dental health care benefits plan.

Investigational / Cosmetic / Not Covered Service

CategoriesInvestigational Service, Cosmetic, or Not a Covered Service — as identified by BlueCross BlueShield of Tennessee under the member's dental health care benefits plan.

Coverage consequenceIf a service is determined to be investigational, cosmetic, or not a covered service, it will be excluded from coverage and the patient will be responsible for all costs.

Patient acknowledgementForm informs the patient that these determinations may be made and documents the patient's acceptance of potential financial responsibility.

OpenPayer

Acknowledgement of Financial Responsibility for Dental Services

Coverage Criteria & Form Conditions

Coding & Form Expiration

Provider Responsibilities & Appeals

Background & Scope

Key Definitions