CurrentOptumPolicy N/A
Member Payment Responsibility Agreement for Non-Medically Necessary Services
Governs the required written agreement between OptumHealth Behavioral Solutions of California providers and members when OptumHealth determines services or supplies are not medically necessary; applies to members and contracted providers in California.
Policy Summary
PayerOptum
PolicyMember Payment Responsibility Agreement for Non-Medically Necessary Services
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain a signed Member Payment Responsibility Agreement and provide notice of denial and appeal rights before the member signs.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
onerequired signed agreement per non-Medically Necessary determination
60 daystimeframe to file civil rights complaint after discovery
1-800-999-9585toll-free language assistance number
TTY 711TTY access for communications
Member Payment Responsibility — Conditions and Member Obligations
Member payment and appeal criteria
Circumstances and member obligations when services/supplies are determined not medically necessary by OptumHealth:
Agreement must be executed prior to provision of services/supplies for which OptumHealth has determined there is lack of medical necessity.
Member must receive a notice of denial that includes information about appeal rights before signing the Member Payment Responsibility Agreement.
Providers must use this specific Member Payment Responsibility Agreement and not substitute it for routine admission, treatment financial responsibility forms, or other general patient payment forms.
By signing the agreement, the member accepts personal financial responsibility for the specified services/supplies received after the signature date, even if the charge does not appear on the EOB as the member's responsibility.
Policy Summary
PayerOptum
PolicyMember Payment Responsibility Agreement for Non-Medically Necessary Services
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain a signed Member Payment Responsibility Agreement and provide notice of denial and appeal rights before the member signs.
SourceLink
On This Page