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.