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25 11/2005
attempt to transfer members from ER facilities, once clinically stable, to the most
appropriate level of care.
Unauthorized Admissions
If an admission or continued stay is determined not to be medically necessary under
the terms of the member’s Membership Agreement by the BCBSGa UM Department,
the member may not be charged for services rendered in connection with the
inappropriate (unauthorized) admission or days, unless the member signed a notice
of potential liability (see examples on pages 25 and 26). Please note that the Notice of
Potential Liability form should only be presented to the member for signature under
the following circumstances: the physician has signed a discharge order for the
member and
the member indicates that he/she refuses to leave the hospital; or the
hospital is notified that a particular service will not be covered by BCBSGa/BCBSHP,
and
the member insists that the service(s) be rendered. Upon appropriate notification
to the member, and with the member’s acceptance of financial responsibility, the
hospital may bill the member for services which are not eligible for reimbursement
because the services are not medically necessary or are not covered under the
member’s Membership Agreement. These forms should not be included in the
member's routine hospital registration paperwork.
In the event that a hospital renders services to a member which are Ineligible Services,
the hospital shall, prior to the provision of such Ineligible Services, inform a member
that: (1) the services to be provided are not reimbursable under a Membership
Agreement or the services are not Medically Necessary; (2) BCBSHP will not pay for or
be liable for such services; and (3) a member will be financially liable for such
services. (This provision does not apply to emergency services.)