Common Contracts

 ANTHEM BLUE CROSS COVERED INDIVIDUAL (PATIENT) RESPONSIBILITY AGREEMENT – WAIVER LETTER

Covered Individual Responsibility Agreement • November 6th, 2012 • California

• Contract Type
  Covered Individual Responsibility Agreement
• Filed
  November 6th, 2012
• Jurisdiction
  California

Contracting Anthem Blue Cross health care professionals/facilities (“Providers”) are prohibited from charging Anthem Blue Cross Covered Individuals for any service or supply that is determined by Anthem Blue Cross to be not Medically Necessary, unless the Covered Individuals specifically agrees in advance of the provision of the service or supply to be financially responsible for payment with specific knowledge of Anthem Blue Cross’ determination that the service or supply was determined to be not Medically Necessary. This Waiver Letter shall be used by the Provider in such instances and must be separate from any patient payment responsibility information in the hospital admission form. To be effective and valid, this Waiver Letter must be executed prior to the delivery of any service or supply that was determined to be not Medically Necessary.