IHCP Patient Waiver

Click here to download the IHCP Patient Waiver Form

From IHCP:

Billing a Member for Noncovered Services

The following guidelines must be met for IHCP providers to hold a member (patient) responsible for payment:

  • The service rendered must be determined to be noncovered by the IHCP or a covered service for which the member has exceeded the program limitations for the particular service.
  • The member must understand before receiving the service that the service is not covered by the IHCP and that the member is responsible for the charges associated with the service.
  • The provider must maintain documentation that the member voluntarily chose to receive the service, knowing that the IHCP will not cover the service.
  • The member should sign a waiver form to acknowledge and indicate the understanding that he or she is financially responsible for all services agreed to and that reimbursement is not available from the IHCP.
  • Providers can bill the member using the usual and customary charge for any services provided that are not covered by the IHCP.


Note on Dentures:

The service of providing dentures to any patient is not complete until the completed denture has been delivered to the patient. The date of the provision of the finished product is the date of service that must be used for claims filing and must be supported by record documentation. The provider must bill the IHCP according to when the services are rendered.

The IHCP requires that provider records be maintained in accordance with 405 IAC 1-5-1. Per 405 IAC 1-5-1(b)(4), the medical record must contain the date when the service was rendered. In addition, according to 405 IAC 1-1-4, denial of claim payment can occur if the services claimed are not documented in accordance with 405 IAC 1-5-1


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