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WAIVER FORM

FOR

• NON-REFERRED SERVICE

• NOT MEDICALLY NECESSARY SERVICE

• EXPERIMENTAL/INVESTIGATIVE SERVICE

I. Provider Information

II. Patient Information

Provider Name: _______________________________________

Patient Name: ________________________________________

Practice Name: _______________________________________

Medical Necessity

Patient ID#: __________________________________________

(Prefix)

(Suffix)

Phone: (_____)_______________________________________

Anthem BCBS pays only for necessary medical and surgical services in keeping

DOB: _____/_____/_____

Sex:

with accepted and ethical medical practice. Services or items which do not meet

Provider Number: _____________________________________

medical necessity criteria are excluded from coverage. A medically necessary

service is a serv- ice which:

III. Waiver Form Statement and Provider Signature

The purpose of this waiver form is to inform Anthem Blue Cross and Blue Shield (Anthem BCBS) members, before they receive a

1.! is appropriate and necessary for the diagnosis, prevention, or treatment of a

medical service, that the service listed below is non-referred or not medically necessary or experimental/investigative. By signing

covered medical condition;

this form, I, the provider acknowledge and agree that I have explained to the member that the service(s) listed are not a covered

2.! is within standards of good and generally accepted medical practice as

service(s).

reﬂected by scientiﬁc and peer medical literature, and recognized within the

_____________________________________________________

_____________________

organized medical community in the State of New Hampshire;

(Provider Signature)

(Date)

3.! provides for the diagnosis, prevention or treatment of a medical condition that

is (i) not excluded from coverage under the Subscriber Coverage Certiﬁcate and

IV. Reason for Waiver Form

(ii) determined by Anthem BCBS, applying Anthem BCBS’s established medical

Non-Referred Service

Not Medically Necessary Service

poli- cies and guidelines, to be covered;

Experimental/Investigative Service

4.! is not primarily for the personal comfort or convenience of the member,

member’s family, physician, or other provider of care;

HMO Members—Non-referred services are not covered by

Not medically necessary and experimental/investigative services

Anthem BCBS and, therefore, are the member’s responsibility.

are not covered by Anthem BCBS and, therefore, are the

5.! is care or treatment which could not have been omitted without adversely

member’s responsibility.

affecting the patient’s condition or the quality of medical care rendered;

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

6.! is not in excess, in terms of scope, duration, or intensity of the level of care

Patient Signature

which is needed to provide safe, adequate, and appropriate diagnosis or treatment;

I have been informed by the provider indicated in Section I. in

7.! is not part of, or associated with, the scholastic education or vocational

advance that the service(s) listed below are services that have

advance that the service(s) listed below are services that are not

education of the member;

not been referred by my primary care provider and are not

medically necessary or are services that are experimental/investi-

8.! is not for investigative or research purposes which are experimental in nature;

covered. I understand and agree that I am responsible for

gative and are not covered. I understand and agree that I am

9.! is not custodial or convalescent care; and 10. in the case of inpatient care,

payment of the provider’s charges for these services to the

responsible for payment of the provider’s charges for these

provider of service.

services to the provider of service.

cannot be provided on an outpatient basis.

If a treatment, service, supply, equipment, or drug does not meet any of the medical

Patient Signature:____________________________________

Patient Signature: ______________________________________

necessity criteria, the treatment, service, supply, equipment, or drug will be

Date: __________________

considered not medically necessary and will be denied. The member may not be

billed for services denied as not medically necessary unless the member has agreed

V. Service(s) To Be Provided

in advance in writ- ing to pay for such services.

Date(s) of Service

Procedure/Service

Procedure Code*

Amount Charged

_____/_____/_____

_______________________________

______________

_____________

_____/_____/_____

_______________________________

______________

_____________

_____/_____/_____

_______________________________

______________

_____________

_____/_____/_____

_______________________________

______________

_____________

*If applicable

An independent licensee of the Blue Cross and Blue Shield Association.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc.

® Registered marks of the Blue Cross and Blue Shield Association.

1894 (7/01)

Form 1894 - Anthem Waiver Form For Non-Referred Service/not Medically Necessary Service/experimental/investigative Service

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