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VERSION 5.3
Presented By
Please note: The approval of the services indicated on the attached Authorizations refer only to the medical appropriateness of the requested service(s) and does not represent a guarantee of payment. Your acceptance of this referral to provide services constitutes your agreement to accept compensation in accordance with your contract with BFMC/HPN/CCPN and AB1455, as payment in full, and to look to the member/patient only for payment of applicable co-payments and/or deductibles. Payment is limited to those services specifically authorized; any additional services require further authorization from BFMC. You further agree to abide by BFMC/HPN/CCPN's Claims, Quality, and Utilization Management policies as are currently in effect. All authorized services are subject to the Member's eligibility to receive care on the date of service.
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performance and other factors. 
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