HMSA provides a form, Acknowledgement of Financial Responsibility ("AFR Form") to be completed by both the provider and the member. The AFR must inform the member that specific medical services, identified by the provider, may not be a benefit of the member's plan and therefore not payable by HMSA. In such a case, the member who completes the form is acknowledging that he or she will be responsible to pay the provider in full for the noncovered services after payment is denied by HMSA.
Providers must explain the provisions of the agreement and the alternatives to the member and provide ample time for the member to review the information before signing the AFR. Members should not be put into the awkward position of being presented a form for signature just as they are being prepared for a procedure.
The signed AFR should be kept in the member's file and a copy should be given to the member for his or her records. Do not attach the AFR to the member's claim unless Modifier GA has been used. (See note below.)
When the claim is processed, the noncovered service will be denied and a message will appear on the member's Report to Member indicating that he or she is not responsible for payment, unless he or she has signed a waiver accepting financial responsibility. Based on the signed waiver, the provider may bill the member for the noncovered service.
Notes:
This AFR is not to be used as a general waiver; rather, it should be used in specific circumstances when procedures may not be deemed medically necessary (i.e., do not meet HMSA's payment determination criteria).
The following are some examples of appropriate and inappropriate procedures related to handling of the AFR:
Appropriate procedures:
- Member is given the AFR during the consultation when the service and alternatives to the procedure are discussed.
- Member has ample time to read the AFR, ask questions and make an informed decision as to whether he or she wishes to go forward with the service, even though it may not be a covered benefit.
- The AFR specifically lists the service(s) to be covered.
Inappropriate procedures:
- Member is given the AFR to sign while being wheeled into a procedure and is told he or she must sign it for the procedure to go forward.
- The AFR is generic and does not specify the service to be performed by the provider.
- An AFR has been signed without the member having been given possible alternatives (if any) that might be covered plan benefits.
GA Modifier:
Even though the provider may bill the member when an AFR has been signed, HMSA Reports to Member will not routinely utilize the GA modifier to show the member's responsibility for payment. HMSA only recognizes the use of the GA modifier in certain limited circumstances. See Modifier Code GA for more information.
Form:
The Acknowledgement of Financial Responsibility may be completed online, printed and signed. Copies may also be printed for your files.
