Get Member Billing Acknowledgment. Required Form

Completing the Member Billing Acknowledgment is an essential step for Medicare Advantage members who seek to self-pay for certain services not covered by their health plan. This guide will provide you with clear instructions to ensure accurate and effective completion of the form online.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Member Billing Acknowledgment and open it in your preferred online editor.
2. Fill in your name in the designated field as the member being treated. Ensure that you accurately spell your name as it appears on your Medicare Advantage plan.
3. Specify the name of the practitioner providing your treatment in the respective field to clearly indicate who will be treating you.
4. Enter the name of your health plan in the specified area. This information is crucial to confirm the correct coverage details.
5. List each service that will not be covered by your Medicare Advantage plan, including dates, procedures, and associated charges, in the provided sections. Be precise and thorough to avoid any confusion.
6. Initial next to each charge to acknowledge your understanding and agreement to self-pay for those services.
7. If you have additional non-covered services, be sure to attach a separate form for those services to ensure your self-pay agreements are clear and complete.
8. Review the acknowledgment statement that you have received your Integrated Denial Notice and have confirmed your financial responsibility. Ensure that the date is filled out accurately.
9. Sign the form to confirm your acknowledgment and understanding of the document. If the member is under the age of 18, a guardian's signature is required.
10. After completing all sections, save any changes made, and download a copy of the form. You may also choose to print or share the completed document as needed.

Complete your Member Billing Acknowledgment form online today to ensure your health care needs are met efficiently.