The financial disclosure forms (FDF) are located on
along with policy
NM007 Non-Covered Services
. The forms are based on the patient’s insurance product and are to be used when/if the patient is requesting elective care or wellness care.
When starting this process, there are several considerations to be made up front:
- Providers need to understand general benefit limitations associated with each line of business that Fulcrum Health, Inc. administers, e.g. Commercial, Medicare, Medicaid, etc.
- Be sure to consider which patients require a pre-service organizational determination of coverage prior to a financial disclosure agreement. This determination protects the patient and ensures they are receiving all medically necessary care they need and will also notify patients if care is not a covered benefit. This requirement applies to tier assigned B and C providers for all insurance products. For A tier providers this is a requirement for Medicare and Medicaid patients only.
Minnesota Medicaid requires submission of claims for elective services in addition to an FDF. At this point the patient can to elect to pay for services not covered.
- Please note that simply having a member sign a waiver when they first begin treatment stating that they understand they are responsible for any services not covered by their insurance is insufficient and does not fulfill your contractual obligations. In order to protect yourself and your patients, it is essential that you review our non-covered services policy as well as your provider manual to ensure that your office is complying. If you choose to not utilize Fulcrum’s FDFs you must ensure that your forms contain each required element listed in Policy NM007.
- It is important to note that new FDFs must be reviewed and signed with the patient every 12 weeks for care not covered under their plan; or for elective care after a new acute episode that has achieved maximum therapeutic benefit.
Here are some other FDF tips
- Include all required elements, per policy, in the FDF
- Complete the FDF with the patient prior to the non-covered services being rendered
- Clearly specify the cost associated with each non-covered service
- Update the FDF every 12 weeks
- Use the Fulcrum FDF to cover policy requirements as other forms used are often insufficient (Standard Financial Waiver, Wellness Program Agreement, Pre-Payment Agreement, Advance Beneficiary Notice, etc.)
For providers that are required to submit a prior authorization, a common error is the lack of submitting a prior authorization for services that may be covered by insurance, or an org determination to confirm if a patient has met maximum therapeutic benefit (MTB). Per Chapter Five of the Provider Manual, Notification is required at the onset of care for new or initial episodes of treatment plans as well as ongoing treatment plans; unless the health plan has a visit waiver. An additional prior authorization request or org determination is a significant component in determining whether a continued course of treatment is medically necessary.
Providers may not bill the patient, or the payor, for the applicable non-covered services if they fail to obtain appropriate documentation as described above. In these cases, the liability of payment falls to the provider. Failure to follow these billing guidelines will often prompt a patient to file a complaint with their health plan and is viewed by Fulcrum, as well as our health plan customers, as a violation of your provider contract. Additionally, failure by the provider to obtain and/or produce acceptable forms upon request could lead to corrective actions or change in network participation status.
Please contact Alexus with any questions regarding the Financial Disclosure Form, billing for non-covered services, authorization protocol calls or how to appropriately transition a member from active to wellness treatment.