New Patient Advance Notice of Noncovered Service(s) form

You may use the new Patient Advance Notice of Noncovered Service(s) form with BCN Advantage HMO‑POS, BCN Advantage HMO or Blue Care Network members if you believe BCN Advantage or BCN will deny payment for a service because it is not medically necessary or is not covered. The Patient Advance Notice of Noncovered Service(s) form allows you to inform members that they could be responsible for the costs associated with the service in question and shows the specific amount for which they could be liable. The form shows that if the member still chooses to receive the service and BCN Advantage or BCN does not pay, the member is responsible for payment.