You may bill recipients only in the following situations:
You may not bill the recipient:
Prohibition on Billing Plan Members – Commercial insurance
Your agreement with the Plan requires providers to accept payment directly from the Plan. Payment from the Plan constitutes payment in full, with the exception of applicable deductibles, co-insurance and any other amounts listed as member responsibility on the Explanation of Payment/Provider Remittance Advice.
Providers may not bill Plan members for:
* The difference between actual charges and the contracted reimbursement amount;
* Services denied because of timely filing requirements;
* Services denied due to failure to follow Plan procedures;
* Covered services for which a claim has been returned and denied for lack of information;
* Remaining or denied charges for those services where a contracted provider fails to notify the plan of a service that required prior authorization; payment for that service will be denied; and
* Covered services that were not medically necessary, in the judgment of the Plan, unless prior to rendering the service, the provider obtains the member’s informed written consent and the member receives information that they would be financially responsible for the specific services.
* Sales tax or GET on services rendered Non-Covered Services
Plan members may be billed for non-covered services like cosmetic procedures and items of convenience (i.e., televisions), services received from unauthorized nonplan providers, in addition to instances when a member self-refers to a specialist or other provider within the network without following Plan procedures (e.g. without obtaining prior authorization) and the Plans denies payment to the provider.
If a provider bills a member for non-covered services or for self-referrals, he or she shall inform the member and obtain prior agreement from the member regarding the cost of the procedure and the payment terms at time of service.