As a reminder, before providing noncovered/excluded services, providers must
furnish Keystone 65 HMO or Personal Choice 65
SM PPO members with
written notice that the services are not covered and the members will be
responsible for payment. Examples of noncovered/excluded services include, but
are not limited to:
comfort and convenience items, such as a total electric hospital bed;
equipment inappropriate for home use, such as a standing frame system;
equipment that is not primarily medical in nature, such as some power
wheelchair accessories (e.g., power seat elevation system, power standing
feature, remote operation);
equipment with features of a medical nature that are not required by the
individual?s condition, such as a water-circulating cold pad with pump;
other examples, including non-elastic binders and gradient compression
stockings (HCPCS codes A6530; A6533-A6549).
This requirement for written notification of noncovered/excluded services and
payment responsibility is contained in your Independence professional provider
agreement, which states that in the event the Provider provides Non-covered or
Excluded services to the Beneficiary, the Provider must inform the Beneficiary
in advance in writing: (i) of the service(s) to be provided; (ii) that
Independence [Blue Cross] will not pay for or be financially liable for said
services; and (iii) that the Member will be financially liable for such
services.
If the provider does not give written notice of noncovered/excluded services to
the member, he or she is required to hold the member harmless.
Our Member Consent for Financial Responsibility for Unreferred/Non-covered
Services form may be used when members request service(s) that are not
covered under their Medicare benefits. This easy-to-use form, which is
available on the
Forms page of
our website, requires the provider to list the type of service that is not
covered. A copy of the form should be given to the member, and a copy should be
made part of his or her medical record.
Please visit the
Medical Policy
portal for more information about noncovered/excluded services.