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
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.