Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Overview Per your provider service agreement, you may not bill:
Any member for medically unnecessary or investigative
services.
Prepaid Medical Assistance Program (PMAP) and
MinnesotaCare members for services that are not covered at
your office, but may be covered if the member went to another
provider.
You may bill the patient only if the following conditions are met:
The patient is notified prior to the service being rendered that
the service is not covered, etc.
The member agrees, by signing a waiver, to pay for the service.
In addition, you should not direct your fee-for-service members to
nonparticipating providers (Refer to Referrals to Nonparticipating
Providers).
One of the DHS regulations includes enrollee rights to notification
of non-covered services. General signed statement information is
included in the Blue Cross Provider Policy and Procedure
Manual, Chapter 6.
The signed statement is allowed only when the service provided is
a non-covered service, and must be:
Specific to the procedure/service (including the cost)
Specific to a date of service
Signed and dated by the enrollee for each date of service
If the signed statement is not signed by the Public Programs
enrollee prior to the service, then according to DHS rules, the
enrollee cannot be billed for the service. This includes services that
are investigative, not medically necessary, or excluded from
coverage under the contract. You may bill an enrollee for noncovered
services only when Minnesota Health Care Programs
(MHCP) never covers the services and only if you inform the
enrollee before you deliver the services that he/she would be
responsible for payment. If MHCP normally covers a service but
the enrollee does not meet coverage criteria at the time of the
service, the provider cannot charge the enrollee and cannot accept
payment from the enrollee.
For example, if an enrollee did not receive a referral for a service
that required one, the service is not eligible for a signed statement;
and, the provider cannot bill the member for the service.
4-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)