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Limited Patient Waiver Clarification

The following is to help clarify not only when to use the Limited Patient Waiver, but to also identify member financial responsibility.  

Non-Covered vs. Not Medically Necessary vs. Experimental or Investigational

Non-covered services/supplies are services/supplies in which benefits are not provided under the member's contract. Non-covered services are the patient's financial responsibility. The contracting provider may collect for these services, in full, at the time they are rendered and/or supplied.

Not medically necessary services are for health care services or supplies that do not meet medical policy requirements and/or do not meet accepted standards of medicine needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. BCBSKS considers these services to be a provider write-off unless a "Limited Patient Waiver" (waiver) is signed prior to the service being provided.

Experimental or investigational services are services, equipment, facility, or supply (including drugs or drug usage) that has not been proven effective to the point that it has been accepted as standard medical practice by the general medical community, and/or does not have federal approval. BCBSKS considers these services a provider write-off unless a waiver is signed prior to the service being rendered.

Non-covered services should not be confused with services that are determined to be not medically necessary, experimental, or investigational.

When filing claims for services considered not medically necessary or experimental/investigational and the patient has signed a waiver prior to services being rendered, report modifier "GA" on the appropriate line item to indicate a waiver is on file.  The service will then become member responsibility instead of a provider write-off.  Waivers must be patient, date of service, reason deemed not medically necessary, service, and amount specific in order to be considered valid. Filing a claim with a copy of the waiver is not necessary.  However, a copy of the waiver should be kept in the patient file and made available upon request.

Note:  A waiver cannot be used to collect the difference between the provider’s charge and the allowed amount on a given covered service, nor can it be used for services that are content to another service provided. However, if the member requests a deluxe item or requests higher end services that may be otherwise covered at a basic level, a waiver can be used to collect the difference between the allowance for the basic service and the charge.

An example of a waiver can be found in Policy Memo No. 1, page 30.

If you have additional questions regarding this latest news article, you can contact your BCBSKS provider representative.

Professional Providers