Tuesday, September 6, 2016

When Beneficiary Statement is Not Required for Physician/Supplier Claim


A. Enrollee Signature Requirements

A request for payment signed by the enrollee must be filed on or with each claim for charge basis reimbursement except as provided below. All rules apply to both assigned and unassigned claims unless otherwise indicated.

1. When no enrollee signature required:

a. Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee.

b. Unassigned claim submitted by a public welfare agency on a bill which is paid.

c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.

2. When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.

3. When another person may sign on behalf of the enrollee:

a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.

b. Enrollee physically or mentally unable to transact business: The request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing the enrollee care or support, or of a governmental agency providing him/her assistance.

c. Enrollee physically or mentally unable to transact business and full documentation is supplied that the enrollee has no one else to sign on his behalf: The physician, supplier, or clinic may sign.

d. Enrollee deceased and bill paid or liability assumed: Person claiming payment should sign. If Form CMS-1500 was signed before the enrollee dies, claimant should sign separate request for underpayment.


4. When request retained in file may cover extended future period:

a. Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.

b. Authorization in files of organization approved under §30.2.8.3 covers all services paid for by that organization under that procedure.

c. Assignment in the files of group practice prepayment plan covers services furnished by the plan during the period of the enrollee’s membership.

d. Assignment in the files of a participating provider (hospital, SNF, home health agency, outpatient physical therapy or speech-language pathology provider or comprehensive rehabilitation facility) or ESRD facility covers physician services for which the provider or facility is authorized to bill, and may cover the physician services furnished in the provider or facility as follows:

• Inpatient services - effective for period of confinement.

• Outpatient services - effective indefinitely.

e. Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of durable medical equipment) or qualified reassignee under §30.2 is effective indefinitely.



B. Physician (Supplier) Signature Requirement

The rules below apply to both assigned and unassigned claims unless otherwise indicated.

1. In a claim for services furnished by an individual physician (or supplier), the physician may:

a. In an unassigned claim, provide an itemized bill on his own letterhead - no physician signature required. A Form CMS-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physician’s own letterhead.

b. Sign item 31 of Form CMS-1500.

c. Sign one time certification letter for machine-prepared claims submitted on other than paper vehicles.

d. Authorize an employee (e.g., nurse, secretary) to enter the physician’s signature in item 31 of the Form CMS-1500.

i. Manually

ii. By stamp-facsimile or block letters

iii. By computer

e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physician’s signature in item 31 of the Form CMS-1500, followed by the agent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent may simply enter the physician’s signature.

2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for the services of the physician, the entity may:

a. In an unassigned claim, provide an itemized bill on its letterhead-no signature necessary. A Form CMS-1500 on which the name or identification code of the billing entity has been stamped or preprinted in item 8 is the equivalent of the reassignee’s own letterhead.

b. Have authorized official sign in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556).

c. Have authorized official sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles.

d. Have authorized employee, e.g., a secretary, enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1d.

e. Have nonemployee agent enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1.e.

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