1.0 SIGNATURE REQUIREMENTS
1.1 The contractor shall comply
with state laws and with corporate policy for requiring signatures
on their private business claims in establishing signature requirements
for financially underwritten TRICARE claims.
1.2 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.
1.3 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.
1.4 The contractor shall return
the claim to the beneficiary for his or her signature, unless the
beneficiary is not competent, if additional personal information
or release of medical information is required to complete claim processing.
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 The claim should be signed
by the parent or legal guardian if the beneficiary is under 18 years
of age.
3.1.1.1 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.
3.1.1.2 The contractor shall request
the parent or 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
• He or she is a Service Member;
or
• The services are related to
venereal disease, substance or alcohol abuse, reproductive health,
or abortion.
3.1.3 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 or 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 or illnesses which are temporary,
the signature waiver needs to specify the inclusive dates of the
condition or 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 The contractor shall process
a claim 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.
5.2 If the
beneficiary is deceased, the claim form must be signed by the legal
representative of the estate.
5.2.1 Documentation
must accompany the claim form to show that the person signing is
the legally appointed representative.
5.2.2 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 The contractor
shall arrange to pay the provider whether network or non-network
for services rendered in accordance with state law and corporate
policy, when there is no legal representation.
6.0 BENEFICIARY SIGNATURE ON FILE
6.1 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.
6.2 The below,
or comparable language acceptable to TRICARE, shall be incorporated
into the provider’s permanent records.
6.2.1 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.”
6.2.2 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.”
6.3 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.
6.4 The provider
shall cooperate with the contractor’s post-payment audits by supplying
copies of the requested signature(s) on file within 21 calendar
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, and
Chapter 11, Section 5 for audit requirements.
6.5 The provider shall correct
any deficiencies found by the contractor’s audit within 60 calendar
days of notification of the deficiency or participation in the signature
relaxation program will be terminated.
6.6 Institutional
Claims
6.6.1 The provider must obtain the
beneficiary or other authorized signature on a permanent hospital admission
record for each separate inpatient admission.
6.6.2 A professional provider submitting
a claim related to an inpatient admission must indicate the name
of the facility maintaining the signature on file.
6.6.3 Claim forms must indicate that
the signature is on file.
6.7 Professional
Provider Claims
6.7.1 Outpatient professional providers
such as physician’s office and suppliers such as Durable Equipment (DE)
and Durable Medical Equipment (DME).
6.7.2 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.
6.7.3 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.
6.8 Outpatient
Ancillary Claims
6.8.1 Outpatient ancillary claims
are claims that are submitted from an independent laboratory where, ordinarily,
no patient contact occurs.
6.8.2 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.”
6.8.3 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.
6.9 Verification
Of Provider’s Compliance With The Beneficiary Signature On File
Requirement
The contractor
shall verify beneficiary signature on file compliance using the
post-payment audit requirement in
paragraph 6.2.2, and
Chapter 1, Section 4, and the audit procedures
in
Chapter 11, Section 5.
7.0 UNACCEPTABLE SIGNATURES
7.1 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.
7.2 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).
7.3 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).
7.4 For those
conditions or illnesses which are temporary, the signature waiver
needs to specify the inclusive dates of the condition/illness.
7.5 If the beneficiary is unable
to sign due to an incapacitating condition or 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
8.1.1 The contractor
shall, for claims for inpatient anesthesia, laboratory and other
diagnostic services in the amount of $50.00 or less provided by
physician specialists in anesthesiology, radiology, pathology, neurology
and cardiology not return for beneficiary signature unless required
by state law or contractor corporate policy.
8.1.2 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 The contractor
shall waive the requirements for a beneficiary’s (sponsor, guardian,
or parent) signature in the following situations for claims received
from non-network participating providers.
8.2.2 The contractor
shall grant a waiver after the procedures described below have proven
unsuccessful.
8.2.3 The contractor
shall attempt to obtain the address by telephone, from internal
files, or Defense Enrollment Eligibility Reporting System (DEERS).
8.2.4 The contractor shall return
the original claim to the beneficiary or sponsor with the request
for signature if a new address is obtained.
8.2.5 The contractor shall grant
a signature waiver for a participating provider if the signature
is not obtained because the new address is still not valid and the
patient cannot otherwise be located.
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 The contractor shall return
the claim if a non-network participating claim does not contain
an acceptable signature.
10.2.1 The provider’s signature is
also required to certify services rendered when a provider completes
a nonparticipating claim for the beneficiary.
10.2.2 The contractor may, if the
provider does not sign, 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 or 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
10.3.1 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).
10.3.2 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.
10.3.3 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
10.4.1 The contractor shall assume,
in the absence of any indication to the contrary, 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.
10.4.2 The contractor shall 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.
10.4.3 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
10.5.1 Source of care certification
is used to help determine the correct payee on the participating
UB92/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.)
10.5.2 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.
10.5.3 Provider signature on file
requirements apply to the claims if not signed.
10.5.4 The contractor shall, if signed
by the provider and the certification is unaltered, issue payment
to that provider.
10.5.5 The contractor shall, if signed
with alteration of the certification, issue payment to the beneficiary (parent
or legal guardian of minor or incompetent).
10.5.6 The contractor shall, 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.