Under the Independence Provider Agreement (Agreement), providers must give Keystone 65 HMO and Personal Choice 65^SM PPO members written notice that non-covered/excluded services are not covered and that the member will be responsible for payment before services are provided. The notice must contain the specific services that are not covered. A generalized waiver form is not acceptable. Should a member file an appeal, the Centers for Medicare & Medicaid Services requires that we include confirmation that the member was informed in advance that the services are not covered. If the provider does not give written notice of specific non-covered/excluded services to the member, then he or she is required to hold the member harmless.

The Independence Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form is used when a member does not have a required referral for nonemergency services or elects to have services performed that are not covered under his or her benefits plan. By signing this form, the member agrees to pay for non-covered services specified on the form. The form must be completed and signed before services are provided. The form is available on our website. Note: This form does not supersede the terms of your Agreement, and you may not bill members for services you are contractually prohibited from billing.

To learn about the procedures for referring HMO and POS members, please read the previously published article, Procedures for referring members for covered and non-covered services.

If you have any questions, please contact your Network Coordinator.