Beneficiary Authorization for Claim Submission - JA DME
Beneficiary Authorization for Claim Submission
A request for payment signed by the beneficiary must be on file or submitted with each claim. All rules apply to both assigned and unassigned claims unless otherwise indicated.
- When no enrollee signature required:
- Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.
- When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.
- When another person may sign on behalf of the enrollee:
- Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.
- 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.
- 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.
- 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.
- When request retained in file may cover extended future period:
- Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.
- Authorization in files of organization approved under Section 220.127.116.11 covers all services paid for by that organization under that procedure.
- Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of DME) or qualified reassignee under Section 30.2 is effective indefinitely.
One-Time Authorization (CMS-1500, Items 12 & 13)
Suppliers may obtain and retain in their files a one-time payment authorization from a beneficiary (or the beneficiary’s representative) applicable to any current and future services. The supplier should have the beneficiary sign a brief statement such as:
Name of Beneficiary _______________________ Medicare ID __________________________
I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in (supplier) ___________________. I authorize any holder of medical information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
Signature ________________________________ Date__________________________
Once the supplier has obtained the beneficiary’s one-time authorization, later claims for those same services can be filed without obtaining an additional signature from the beneficiary. These claims may be on an assigned or non-assigned basis with the exception of DME rentals. The one-time authorization for DME rental claims is limited to assigned claims.
Any supplier using the one-time authorization procedure agrees to the following:
- Authorization must be renewed if a new item is rented or purchased.
- Retaining the signed and dated one-time payment authorization form in the supplier's file.
- CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 50.1.2
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.1.6
Last Updated Fri, 24 Feb 2023 19:55:06 +0000