The member will not be held financially responsible for the cost of covered services except for any applicable copayment, coinsurance, or deductible if all of the following are true:

• The member has followed the guidelines of the Plan.
• The PCP or participating specialist fails to obtain pre-certification with Blue Medicare HMO and Blue Medicare PPO Healthcare Services Department for those covered services which require pre-certification.
• The non-precertified covered services have already been rendered.

The member will not be held financially responsible for the cost of noncovered services except for any applicable copayment, coinsurance, or deductible if the noncovered services are rendered before the member receives an organization determination from Blue Cross NC denying coverage.

In either instance, the participating provider will be advised that they must write-off the cost of the non-certified or noncovered services and hold the member financially harmless according to contract provisions.

Ancillary services provided in conjunction with non-precertified services are also not payable by the Plan unless the ancillary provider is a non-participating provider.

This policy will also apply when Plan is the secondary payer of claims.

Members will be held responsible for non-certified services when the member receives an organization determination from Blue Cross NC denying coverage before the services are rendered.