CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Member (Patient) Responsibility Agreement / Waiver for Non‑Covered Services

Defines the required written waiver form and process by which Anthem Blue Cross members may agree in advance to pay for services or supplies determined by Anthem Blue Cross to be not medically necessary or not covered. Applies to contracting Anthem Blue Cross providers and affected members.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMember (Patient) Responsibility Agreement / Waiver for Non‑Covered Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a signed member waiver prior to delivering any service or supply determined to be not medically necessary or non-covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required waiver form for advance member agreement

3form sections

1send waiver with initial claim

0may charge without signed waiver

Member Financial Responsibility Conditions

Conditions under which a provider may collect payment from a member for services or supplies Anthem Blue Cross has determined to be not medically necessary or not covered:

Provider must obtain a written waiver signed by the member prior to providing the non‑medically necessary or non‑covered service or supply.

The waiver (or other separate writing documenting the same information) must be executed prior to delivery and must be separate from any patient payment responsibility information in the hospital admission form.

The waiver must document, for each listed item, the description of the service or supply, the approximate cost, and the member's financial responsibility.

The provider must attach and send a completed copy of the signed waiver form with the initial claim to the claims address on the member's identification card for claims processing.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMember (Patient) Responsibility Agreement / Waiver for Non‑Covered Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a signed member waiver prior to delivering any service or supply determined to be not medically necessary or non-covered.

SourceLink

On This Page

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Form Fields and Coding Notes

Not specifiedmixed

No codes listed

Form fields — repeatable service entries

Repeatable form entriesForm includes repeatable entries for each item: Description of service and/or supply; Approximate cost; Member's (Patient's) Responsibility.

Description fieldA free-text entry labeled 'Description of Service and/or supply' for each listed item.

Approximate cost fieldAn entry labeled 'Approximate Cost of service and/or supply' to record estimated charges for each listed item.

Member responsibility fieldAn entry labeled 'Member's (Patient's) Responsibility' to document the amount the member agrees to pay for each listed item.

SignatureForm provides a signature line to evidence the member's agreement to the listed item(s) and financial responsibility.

Provider Requirements and Claims Handling

Prior Authorization

Advance Waiver Requirement

Obtain a signed member waiver before providing any service or supply that Anthem Blue Cross has determined to be not Medically Necessary or non‑covered. The waiver must be separate from hospital admission payment information and executed prior to delivery of the service or supply.

Waiver must document the member's agreement to be financially responsible for services or supplies determined by Anthem Blue Cross to be not Medically Necessary or non‑covered.
Waiver must be executed prior to the delivery of any non‑Medically Necessary or non‑covered service or supply.
Waiver must be separate from any patient payment responsibility information in the hospital admission form.

Billing Rule

Claims Submission Requirement

Attach and send a completed copy of the signed waiver form with the initial claim to the claims address on the member's ID card for appropriate claims processing.

Send the completed waiver along with the initial claim to the claims address on the member (patient)'s identification card.
This submission does not renegotiate any already negotiated rate between Provider and Anthem Blue Cross.

Member Responsibility Agreement / Waiver

Member Responsibility Agreement / Waiver — definition and purpose

DefinitionA written waiver or other separate writing executed prior to delivery of service that documents the member's agreement to be financially responsible for services or supplies Anthem Blue Cross has determined to be not Medically Necessary or non-covered.

Timing requirementTo be effective and valid, the waiver must be executed prior to the delivery of any non‑Medically Necessary or non‑covered service or supply.

Separate document requirementThe waiver must be separate from any patient payment responsibility information in the hospital admission form.

Appeal rights notedForm informs members that the provider and/or member may appeal Anthem determinations through Anthem's grievance/appeal process or seek Independent Medical Review through the DMHC as described in the member's Evidence of Coverage.