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 -