Claims Processing Procedures
Chapter 8
Addendum A
Figures
Revision:
Figure 8.A-1 Provider’s
Notarized Facsimile Or Stamp Signature Authorization
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State of ____________________)
___________________________)ss
County of __________________)
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____________________________________
being first duly sworn, deposes and says: I hereby authorize the (Contractor
for TRICARE in the State) of to accept my facsimile or stamp
signature shown below.
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(Facsimile,
stamp or computer generated signature as it will appear on the claim
form.)
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As
my true signature for all purposes under TRICARE in the same manner
as if it were my actual signature, including my agreeing to abide
by the TRICARE payment system concept and the remainder of the certification
normally signed by the source of care as it appears on all TRICARE
claim forms.
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Signature
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Subscribed
and sworn to before me this ________ day of 20____.
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_____________________________________________
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Notary
Public in and for
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_________________
County, State of ______________
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(SEAL)
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My
Commission expires _____________________________________
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Figure 8.A-2 Provider’s
Notarized Signature Authorization
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State of ____________________)
___________________________)ss
County of __________________)
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Know
all persons by these presents:
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That
I, __________________________ have made, constituted and appointed
and by these presents do make constitute and appoint ______________________
my true and lawful attorney-in-fact for me and in my name place
and stead to sign my name on claims, for payment for services provided
by me and submitted to TRICARE. My signature by my said attorney-in-fact
includes my agreement to abide by the TRICARE payment system concept
and the remainder of the certification appearing on all TRICARE claims
forms. I hereby ratify and confirm all that my said attorney-in-fact
shall lawfully do or cause to be done by virtue of the power granted
herein.
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In
witness whereof I have hereunto set my hand this _________day of
_______________ 20___.
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Signature
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Subscribed
and sworn to before me this ________ day of 20____.
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_____________________________________________
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Notary
Public in and for
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_________________
County, State of ______________
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(SEAL)
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My
Commission expires _____________________________________
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Figure 8.A-3 Abortion
Denial Notice To The Beneficiary And Participating Provider
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Date: ____________________________
Sponsor’s Name: __________________
Beneficiary’s Name: ________________
Type of Service(s): _________________
Date of Service(s): _________________
Last four digits of
Sponsor’s SSN: ____________________
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PERSONAL
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_____________________________
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To:
__________________________
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_____________________________
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Dear
_________:
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TRICARE
coverage of abortion services is specifically limited by federal
statute. As implemented by the Department of Defense, TRICARE coverage
of abortion services is limited to when:
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• The life of the mother is at risk if the fetus
is carried to term -- based upon certification from the attending
physician that the patient suffers/suffered a condition that endangered
her life if the fetus were carried to term; or
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• The pregnancy is the result of an act of rape
or incest -- as documented in the patient’s medical record (effective
January 2, 2013).
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This
means TRICARE won’t cost-share on abortions performed for reasons
other than those listed above. Since initial review of your claim(s)
gave no indication that this abortion met the conditions for coverage,
TRICARE denied the claim.
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If
you believe you do qualify under one of the exceptions, you may
request a Reconsideration of the denial decision by submitting a
written Reconsideration request to this office within 90 days of
the date of this notice. Your request must include a copy of this
notice, a statement outlining why you disagree with the decision,
and any additional information/documentation from your physician
which will support your position.
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If
you have any questions concerning the TRICARE abortion policy, please
contact (Contractor Name and Address).
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Sincerely,
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- END -