Billing patient for non - covered service - consent form

Charging members for non-covered services

For Commercial members, you may seek and collect payment from our member for services not covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. In those instances in which you know or have reason to know that the service may not be covered (as described below), the written consent also must: (a) include an estimate of the charges for that service; (b) include a statement of reason for your belief that the service may not be covered; and (c) in the case of a determination by us that planned services are not covered services, include a statement that UnitedHealthcare has determined that the service is not covered and that the member, with knowledge of UnitedHealthcare’s determination, agrees to be responsible for those charges.

For Medicare Advantage members, a Notice of Denial of Medical Coverage must be provided to the member advising them when a service is not covered.

You should know or have reason to know that a service may not be covered if:

• We have provided general notice through an article in a newsletter or bulletin, or information provided on our Web site (UnitedHealthcareOnline.com), including clinical protocols, medical and drug policies, either that we will not cover a particular service or that a particular service will be covered only under certain circumstances not present with the member; or

• We have made a determination that planned services are not covered services and have communicated that  determination to you on this or a previous occasion.

You must not bill our member for non-covered services if you do not comply with this Protocol.

If you do not obtain written consent as specified above, the rendering provider must accept full financial liability for the cost of care. General agreements to pay, such as those signed by the member at any time (including at admission or upon the initial office visit), are not considered written consent under this Protocol.