CurrentOptumPolicy N/A

Convenio de Responsabilidad de Pago del Miembro (Paciente)

Establece el acuerdo por escrito que permite a proveedores cobrar a miembros por servicios o suministros que OptumHealth determinó no son médicamente necesarios; aplica a miembros de OptumHealth Behavioral Solutions of California y a proveedores contratados en California.

Policy Summary

PayerOptum

PolicyConvenio de Responsabilidad de Pago del Miembro (Paciente)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must obtain a signed member Payment Responsibility Agreement prior to providing services determined not Medically Necessary and after the member has received a denial notice with appeal rights.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1formulario requerido

Californiajurisdicción

1-800-999-9585asistencia lingüística

Optum Civil Rights Coordinatorcontacto no discriminación

Payment Responsibility When Services Are Not Medically Necessary

Payment responsibility for non-medically necessary services

Stance and required process when services are determined not Medically Necessary:

ALL of the following

ALL of the following
- Provider must present and obtain the member's (or authorized representative's) signature on the Payment Responsibility Agreement prior to providing the service or supply that OptumHealth has determined is not Medically Necessary.
  Agreement must be separate from other admission or treatment financial forms and used in these cases.
- The Payment Responsibility Agreement must be signed before the service or supply is provided (in advance of care).
ALL of the following

Policy Summary

PayerOptum

PolicyConvenio de Responsabilidad de Pago del Miembro (Paciente)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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The member must have received a denial notice from OptumHealth that includes information about appeal rights prior to signing the Payment Responsibility Agreement.

Member must have been informed and specifically acknowledged that OptumHealth determined the service or supply was not Medically Necessary.

ALL of the following

By signing, the member acknowledges they understand the service(s) were determined not Medically Necessary and that they will be personally and financially responsible to pay the provider for the specified services or supplies.
Signing does not limit the member's rights to file an appeal with OptumHealth or the DMHC or to seek an Independent Medical Review, and an appeal does not guarantee the member will not be financially responsible.

ALL of the following

Providers are prohibited from charging the member for services or supplies determined not Medically Necessary unless the member (or authorized representative) has specifically signed the Payment Responsibility Agreement in advance.
If the member has not signed the Agreement prior to service, the provider may not bill the member for those services or supplies.

ALL of the following

The provider must use the Payment Responsibility Agreement form in these cases and keep it separate from general patient financial responsibility or admission forms.
The Agreement must identify the member, provider, and list the specific services or supplies for which the member will be financially responsible.

Member rights

Member retains the right to file a formal complaint or appeal with OptumHealth.
Member may appeal determinations and seek an Independent Medical Review through the Department of Managed Health Care (DMHC) as described in the Evidence of Coverage.

Provider Duties and Required Agreements

Documentation Required

Get signed Payment Responsibility Agreement before furnishing non‑medically necessary services

Obtain a signed Member Payment Responsibility Agreement before providing services OptumHealth has determined are not Medically Necessary. The Agreement must be signed after the member has received the denial notice (including appeal rights) and prior to delivery of the service or supply.

Use the designated Payment Responsibility Agreement form separate from any standard admission or financial responsibility forms.
Member (or authorized representative) must sign the Agreement acknowledging OptumHealth determined the service was not Medically Necessary and that they may be personally responsible for payment.
Do not bill the member for the service or supply unless the Agreement was signed in advance of the service.

Key Definitions and Member Rights

Convenio de Responsabilidad de Pago — definición y requisitos

Definition (Spanish title)Convenio de Responsabilidad de Pago del Miembro (Paciente): escrito firmado por el Miembro o su representante autorizada aceptando responsabilidad financiera personal por servicios o suministros que OptumHealth determinó no son Médicamente Necesarios.

Timing requirementEl convenio SE DEBE celebrar con anticipación a la prestación del servicio o suministro para que sea vigente y válido.

Pre-signature conditionsEl Miembro debe haber recibido un aviso de denegación que incluya información sobre sus derechos de apelación antes de firmar.

Limitation on billingSin la firma del Miembro, el Proveedor no puede cobrar personalmente por los servicios o suministros determinados no Médicamente Necesarios.

Reference to law/regulationConforme al Código de Salud y Seguridad de California §1379 y 28 CCR §1300.71(g)(4).

Derechos de apelación y recursos del Miembro

Right to appeal to OptumHealthEl Miembro puede presentar una queja formal o apelación ante OptumHealth conforme a los procedimientos descritos en su Comprobante de Cobertura (Evidence of Coverage).

Independent Medical Review (IMR)El Miembro puede solicitar una Revisión Médica Independiente (Independent Medical Review) a través del Departamento de Cuidado de la Salud Administrado (DMHC) según lo descrito en su Comprobante de Cobertura.

No limitation of other rightsNada en el convenio limita otros derechos que el Miembro tenga conforme a leyes estatales o federales.