1.0 Signature
Requirements
1.1 In establishing signature requirements for
financially underwritten TRICARE claims, the contractor shall comply
with state laws and with corporate policy for requiring signatures
on their private business claims. However, when the private or state
signature requirements conflict with Federal Privacy Act, Health
Insurance Portability and Accountability Act (HIPAA), or Freedom
of Information Act (FOIA) requirements, the latter shall prevail.
1.2 The contractor
shall comply with the following requirements in processing non-network TRICARE
claims for which the signature of the beneficiary, spouse, or parent
or guardian of a beneficiary is required unless qualifying for an
exception. If additional personal information or release of medical information
is required to complete claim processing, the claim shall be returned
to the beneficiary for his/her signature, unless the beneficiary
is not competent.
2.0 Privacy
Act Requirements Custodial/Noncustodial Parent
Any
relaxation of signature requirements does not, in any way, relax
the confidentiality requirement imposed by the Privacy Act. Checks,
Explanations of Benefits (EOBs), responses to inquiries, etc., shall
be addressed to the beneficiary or parent or guardian of a beneficiary
who is incompetent or under 18 years of age. Under the provisions
of the Privacy Act of 1974, neither Defense Health Agency (DHA)
nor a claims processor shall provide the non-custodial parent with
any information concerning the processing of TRICARE claims for
the minor children without the written consent of the custodial
parent. In the case of divorce or legal separation only the custodial
parent shall have access to the medical record(s), unless the divorce
or legal separation decree gives rights to the records to the non-custodial
parent. Questions regarding custodial parent issues should be addressed to
the DHA Office of General Counsel (OGC).
3.0 Beneficiary
Is Under 18 Years Of Age
3.1 Non-Participating
Provider Claims
3.1.1 Normally, the claim should be signed by the
parent or legal guardian if the beneficiary is under 18 years of
age. However, if the beneficiary signs the claim form legibly, the
claim should be processed unless there is other reason to return
the claim form, or doing so conflicts with state law or contractor
policy. Request the parent/legal guardian signature if the claim
form is returned except for the two exceptions listed below. In
the following situations, a beneficiary under 18 years of age may always
sign the claim form in his or her own behalf in accordance with
state laws related to the age of consent and the Federal Privacy
Act.
3.1.2 Exceptions
• He
or she is (or was) a spouse of a Service member or retiree; or
• The services are
related to venereal disease, substance or alcohol abuse, or abortion.
3.2 Participating
Provider Claims
If a claim is signed by a
beneficiary who is under 18 years of age but the provider agrees
to participate, it is not necessary to obtain the signature of the
parent/legal guardian.
4.0 Beneficiary
Is 18 Years Of Age Or Older (Incompetent Or Incapable)
4.1 When the
beneficiary is mentally incompetent or physically incapable, the
person signing should be either the legal guardian, or in the absence
of a legal guardian, a spouse or parent of the patient. The person
signing should:
• Write the beneficiary’s
name in the appropriate space on the claim form, followed with the word
“by” and his or her own signature;
• Include a statement
that a legal guardian has not been appointed, if such is the case;
• Include documentation
of appointment if a legal guardian has been appointed or if a power
of attorney has been issued. Attach a statement giving his or her
full name and address, relationship to the patient, and the reason
the patient is unable to sign. Beneficiaries who have no legal guardian
or family member available to sign claims, can provide documentation
(i.e., a report from a physician describing the physical and or mental
incapacitating illness). For those conditions/illnesses which are
temporary, the signature waiver needs to specify the inclusive dates
of the condition/illness.
4.2 A beneficiary
who is physically incapable of signing their signature can have
a general or limited power of attorney issued by having their “mark”
(e.g., an “X”) witnessed and notarized.
5.0
Beneficiary
Deceased
5.1 If the provider of care has an approved signature
on file agreement and the beneficiary expires, the authorization
for payment will satisfy the signature requirements and the contractor
shall process the claim.
5.2 If the beneficiary is deceased,
the claim form must be signed by the legal representative of the estate.
Documentation must accompany the claim form to show that the person
signing is the legally appointed representative. If no legal representative
has been appointed, the claim form may be signed by the parent,
the spouse, or the next of kin. The signer must provide a statement
that no legal representative has been appointed. The statement should
contain the date of the beneficiary’s death and the signer’s relationship
to the beneficiary to enable the contractor to update the history
file.
5.3 When there is no legal representative, the
contractor shall arrange to pay the provider whether network or
non-network for services rendered in accord with state law and corporate
policy.
6.0
Beneficiary
Signature On File
Use of the signature on
file procedure is the provider’s indication that he or she agrees
that verification of the beneficiary’s TRICARE eligibility at the
time of admission or at the time care or services are provided is
required prior to any TRICARE payment. The below, or comparable
language acceptable to TRICARE, shall be incorporated into the provider’s
permanent records.
6.1 Institutional
Providers
“I request payment of
authorized benefits to me or on my behalf for any services furnished
me by (Name of Provider), including physician services.
I authorize any holder of medical or other information about me
to release to (Contractor’s Name) any information needed
to determine these benefits or benefits for related services.” Professional
providers who submit claims on the basis of an institution’s signature
on file should include the name of the institutional provider that
maintains the signature on file. The Centers for Medicaid and Medicare
Services (CMS) 1450 UB-04 instructions shall be followed for certifying
signature on file except that the permanent hospital record containing
a release statement will be recognized. “Institutional” includes
all claims related to an institution.”
6.2 Professional
Providers
“I request that payment
of authorized benefits be made either to me or on my behalf to Dr.
__________, for any services furnished me by that physician. I authorize
any holder of medical information about me to release to (Contractor’s
Name) any information needed to determine these benefits
or the benefits payable for related services.”
6.2.1 If a claim
is submitted by a nonparticipating provider and payment will not
be made to the patient, the provider must indicate the name, address,
and relationship of the person to whom payment will be made. This
will be the sponsor, other parent or a legal guardian for minor
children or incompetent beneficiaries, except for claims involving
abortion, venereal disease or substance/alcohol abuse.
6.2.2 The
provider shall cooperate with the contractor’s postpayment audits
by supplying copies of the requested signature(s) on file within
21 days of the date of the request and/or allow the contractor access
to the signature files for purposes of verification. See
Chapter 1, Section 4, paragraph 4.1 and
Chapter 11, Section 5, paragraph 6.3 for audit
requirements.
6.2.3 The provider shall correct
any deficiencies found by the contractor’s audit within 60 days
of notification of the deficiency or participation in the signature
relaxation program will be terminated.
6.3 Institutional
Claims
The provider must obtain the beneficiary
or other authorized signature on a permanent hospital admission
record for each separate inpatient admission. A professional provider
submitting a claim related to an inpatient admission must indicate
the name of the facility maintaining the signature on file. Claim
forms must indicate that the signature is on file.
6.4 Professional
Provider Claims
Outpatient professional providers
such as physician’s office and suppliers such as Durable Equipment
(DE) and Durable Medical Equipment (DME). Authorized individual
providers have the option to retain on their own forms appropriate
beneficiary release of information statements for each visit or
obtain and retain in the provider’s files a one-time payment authorization
applicable to any current and future treatment that the authorized
individual provider may furnish the beneficiary. Claim forms shall indicate
that the signature is on file.
Note: On the claim form for Telemedicine
services, originating telemedicine site provider may indicate “Signature
not required - Distant Telemedicine Site” in the required Patient
Signature field.
6.5 Outpatient Ancillary Claims
Outpatient ancillary claims are claims that
are submitted from an independent laboratory where, ordinarily,
no patient contact occurs. A provider submitting a claim for diagnostic
tests or test interpretations, or other similar services, shall not be required
to obtain the patient’s signature. These providers shall indicate
on the claim form: “patient not present.” For services when there
is patient contact, such as services furnished in a medical facility
which is visited by the beneficiary, the same procedure used for
professional claims for outpatient services shall
be required, except that the provider shall indicate
along with “signature on file” information, the name of the supplier
or other entity maintaining the signature on file.
7.0 Unacceptable
Signatures
A provider or an employee of an
institution providing care to the patient may not sign the claim form
on behalf of the beneficiary under any circumstances. Nor can an
employee of a contractor execute a claim on behalf of a beneficiary
(unless such employee is the beneficiary’s parent, legal guardian,
or spouse). Beneficiaries, who have no legal guardian or family
member available to sign claims, can provide documentation (i.e.,
a report from a physician describing the physical and/or mental
incapacitating illness). For those conditions/illnesses, which are
temporary, the signature waiver needs to specify the inclusive dates
of the condition/illness. If the beneficiary is unable to sign due
to an incapacitating condition/illness, the provider can annotate
in the Signature Box on the TRICARE claim form “Unable to sign.”
A letter from the provider shall be attached to the claim form describing
the physical and or mental incapacitating illness. For those illnesses,
which are temporary, the letter needs to specify the inclusive dates
of the illness.
8.0 Beneficiary
Signature Waiver
8.1 Administrative
Tolerance - Certain Ancillary Services
Claims
for inpatient anesthesia, laboratory and other diagnostic services
in the amount of $50 or less, provided by physician specialists
in anesthesiology, radiology, pathology, neurology and cardiology
should not be returned for beneficiary signature unless required
by state law or contractor corporate policy. Claims submitted by
an institution when the claim is for those specific ancillary services
cited above, should be included in this tolerance if the services
were performed in an institution other than the institution in which
the beneficiary is receiving inpatient care.
8.2 Beneficiary
(Sponsor, Guardian Or Parent Moved) Unable To Locate
8.2.1 Requirements for a beneficiary’s
(sponsor, guardian or parent) signature should be waived in the
following situations for claims received from non-network participating
providers. The contractor shall grant a waiver after the procedures
described below have proven unsuccessful. If unable to obtain a
signature because the beneficiary has moved and left no forwarding
address, the contractor shall attempt to obtain the address by telephone,
from internal files, or Defense Enrollment Eligibility Reporting
System (DEERS).
8.2.2 If a new address is obtained,
the original claim shall be returned to the beneficiary or sponsor
with a request for signature. If the claim was submitted by a provider,
a copy, with the diagnosis and any sensitive information deleted,
shall be sent to the beneficiary or sponsor. If the signature is
not obtained because the new address is still not valid and the
patient cannot otherwise be located, the contractor shall grant
a signature waiver for a participating provider. Nonparticipating provider
claims must be denied. However, if the address is valid, and the
contractor knows, through the claim development process, that the
beneficiary or sponsor does not wish to file a claim, the claim(s) must
be denied whether or not the provider participates. If the contractor
obtains a new address, this address cannot be released to the provider.
9.0 Network
Provider Signature
Signature requirements
for network providers are dependent upon the provisions of the agreement
and administrative procedures established between the providers
and the contractor.
10.0 Non-Network
Provider signature
10.1 The signature of the non-network provider,
or an acceptable facsimile, is required on all participating claims.
10.2 If a non-network
participating claim does not contain an acceptable signature, return
the claim. The provider’s signature is also required to certify
services rendered when a provider completes a nonparticipating claim
for the beneficiary. If the provider does not sign, the contractor
may contact the provider by telephone to verify the delivery of
services or return the claim for signature. A claimant may also
attach an itemized bill on the letterhead/billhead of the provider
verifying delivery of services.
Note: The provider’s
signature block Form Locator (FL) has been eliminated from the CMS
1450 UB-04. As a work around, the National Uniform Billing Committee
(NUBC) has designated FL 80, “Remarks”, as the location for the
signature, if signature on file requirements do not apply to the
claim.
10.3 Facsimile
Or Representative Signature Authorization
In
lieu of a provider’s actual signature on a TRICARE claim, a facsimile
signature or signature of a representative should be accepted if
the contractor has on file a notarized authorization from the provider
for use of a facsimile signature (
Addendum A, Figure 8.A-1) or a notarized authorization
or power of attorney for another person to sign on his or her behalf
(
Addendum A, Figure 8.A-2). The facsimile signature
may be produced by a signature stamp or a block letter stamp, or
it may be computer-generated, if the claim form is computer-generated.
The authorized representative may sign using the provider’s name
followed by the representative’s initials or using the representative’s
own signature followed by Power of Attorney (POA), or similar indication
of the type of authorization granted by the provider.
10.4 Verification
Of Provider Signature Authorization
In the
absence of any indication to the contrary, contractors should assume
the proper authorization is on file, validating through file checks,
those claims containing facsimile and representatives’ signatures
which are included in their quality control audit and program integrity samples.
The contractor should remind providers of the requirement for current
signature authorizations through at least an annual notice in routine
bulletins or newsletters and at other appropriate times when contacts
are made. The contractor may return a claim with a request for the signature
authorization when it is found that there is no authorization on
file or it is out-of-date as follows:
• Send a request to
the provider advising of the need for authorization; and
• Set a utilization
flag on the provider’s file to stop further payment to the provider
when the proper signature is not on the claim, pending receipt of
the authorization.
• Advise
the provider that if the authorization is not received, it will
be necessary to deny the claim or to process it as a nonparticipating
claim, depending on the information available to make a payment
determination.
• Schedule
a contractor representative visit to resolve any problem which may
develop in the unlikely event a provider chooses not to cooperate.
10.5 Certification
Of Source Of Care
Source of care certification
is used to help determine the correct payee on the participating
UB-92/UB-04 and the CMS 1500. (The CMS 1450 UB-04 eliminated the
provider’s signature block FL from the form. As a work around, the
NUBC has designated FL 80, “Remarks”, as the location for the signature, if
signature on file requirements do not apply to the claim.) Submission
of the UB-04 claim form by an institution or provider certifies
the institution or provider is complying with all the TRICARE certifications
on the reverse of the claim. Provider signature on file requirements
apply to the claims if not signed. If signed by the provider and
the certification is unaltered, issue payment to that provider.
If signed with alteration of the certification, issue payment to
the beneficiary (parent/legal guardian of minor or incompetent).
If unsigned and an itemized billing on the provider’s letterhead
is not attached, return the claim.
Note: For procedures in case of any irregularities,
refer to
Chapter 13, Program Integrity.