CurrentOptumPolicy N/A

Member Payment Responsibility Agreement for non‑Medically Necessary Services

Governs the use and execution of a written Payment Responsibility Agreement when OptumHealth determines services or supplies are not medically necessary; affects OptumHealth Behavioral Solutions of California 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 ActionProvider must obtain a completed Payment Responsibility Agreement executed by the member (or authorized representative) prior to delivering services or supplies determined not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

signed prior to servicetiming requirement for agreement validity

includes interpreter accesslanguage assistance

DMHC rights referencedappeal & IMR info

Member Payment Responsibility Conditions

Member financial responsibility for non‑medically necessary services

Conditions under which a member may be charged for services or supplies deemed not medically necessary by OptumHealth:

Member must be informed that OptumHealth has determined the service or supply is not Medically Necessary and must have received notice of the denial including information about appeal rights (grievance/appeal with OptumHealth or the Department of Managed Health Care and the right to request Independent Medical Review).

Provider must present a separate Payment Responsibility Agreement and obtain the member's (or authorized representative's) signed agreement in writing prior to delivery of the disputed services or supplies.

The Payment Responsibility Agreement must be executed in advance of the provision of the service or supply and must be separate from standard admission or treatment-onset paperwork or other patient payment responsibility forms.

Signing the Agreement does not waive the member's right to file a grievance or appeal or to request Independent Medical Review; an appeal does not guarantee that the member will not be personally financially responsible for services provided during the appeal process.

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

SourceLink

On This Page

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Coding and Timing Details

Not applicablemixed

No codes listed

Notesmixed

Execution timing	This Payment Responsibility Agreement MUST be executed in advance of the provision of the service or supply and must be executed prior to delivery; member must have received notice of the denial including information regarding their appeal rights.
Separation requirement	Agreement must be separate from any patient payment responsibility information signed at treatment onset or part of provider/facility admission forms.

Agreement timing

Timing requirementAgreement must be executed in advance and prior to delivery of the disputed service or supply to be effective and valid.

Notice to memberMember must have been informed that OptumHealth determined the service or supply is not medically necessary and must have received notice of the denial including appeal rights.

Separate documentAgreement must be separate from standard patient payment responsibility information or admission/treatment onset forms.

Provider prohibition without agreementProviders are prohibited from charging members for services/supplies determined not medically necessary unless the signed Agreement is executed prior to service delivery.

Provider Responsibilities and Required Documentation

Prior Authorization

Execute Payment Responsibility Agreement prior to service

Obtain a completed Payment Responsibility Agreement signed by the member (or authorized representative) before providing the disputed service or supply. The Agreement must be executed in advance of the provision of the service or supply and the member must have received notice of the denial, including information about their appeal rights.

Agreement must be separate from standard admission or treatment-onset paperwork.
Member must specifically acknowledge awareness that OptumHealth determined the service or supply was not medically necessary.

Defined Terms

Payment Responsibility Agreement — definition

DefinitionA separate, signed document executed in advance of the provision of services or supplies for which OptumHealth has determined the item is not medically necessary, wherein the member agrees to be personally responsible for payment.

Execution timingMust be executed prior to the delivery of the service or supply to be effective.

Separate from admissions paperworkMust be separate from any patient payment responsibility information signed at treatment onset or part of provider/facility admission forms.

Member acknowledgementMember must specifically acknowledge awareness that OptumHealth determined the service/supply was not medically necessary.

IMR and grievance/appeal rights

Right to appeal to OptumHealthMember may file a grievance or appeal with OptumHealth pursuant to the grievance and appeals procedures described in the member's Evidence of Coverage.

Right to contact DMHCMember may file a grievance or appeal with the Department of Managed Health Care (DMHC).

Independent Medical Review (IMR)Member has the right to request Independent Medical Review through the DMHC as described in the member's Evidence of Coverage.

Signing does not waive rightsSigning the Agreement does not limit other rights under state or federal law and does not preclude pursuing appeals or IMR.