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 or DoD Benefits Number (DBN): ______________
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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
• 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 calendar 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 -