Signature Requirements for Claim Submission

Beneficiary Signature

A request for payment signed by the beneficiary 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:
    • Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee
    • Unassigned claim submitted by a public welfare agency on a bill which is paid.
    • Enrollee deceased, bill unpaid and physician or supplier agrees to accept Medicare approved amount as full charge
  2. When signature by mark is permitted: Enrollee is unable to sign his/her name because of illiteracy or physical handicap
  3. When another person may sign on behalf of the enrollee:
    • Enrollee who is resident of a nonprofit retirement home gives power of attorney to administrator of home
    • Enrollee physically or mentally unable to transact business: Request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing 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 enrollee has no one else to sign on his/her behalf: 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 enrollee dies, claimant should sign separate request for underpayment
  4. When request retained in file may cover extended future period:
    • Assignment in files of welfare agency covers all services furnished during period when enrollee is on medical assistance
    • Authorization in files of organization approved under Section 30.2.8.3 covers all services paid for by that organization under that procedure
    • Assignment in files of group practice prepayment plan covers services furnished by plan during period of enrollee's membership
    • Assignment in files of a participating provider (hospital, skilled nursing facility (SNF), home health agency (HHA), outpatient physical or speech therapy provider, or comprehensive rehabilitation facility) or ESRD facility covers physician services for which provider or facility is authorized to bill, and may cover physician services furnished in provider or facility as follows:
      • Inpatient services – effective for period of confinement
      • Outpatient services – effective indefinitely
    • 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)

CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 50.1.2

Suppliers may obtain and retain in their files a one-time payment authorization from a patient (or the patient's representative) applicable to any current and future services. The supplier should have the patient 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 patient's one-time authorization, later claims for those same services can be filed without obtaining an additional signature from the patient. 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 signed and dated one-time payment authorization form in supplier's file

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), physician may:
    • In an unassigned claim, provide an itemized bill on his/her letterhead – no physician signature required. A CMS-1500 form on which physician name or identification code has been stamped or preprinted in Item 25 is equivalent of physician's letterhead
    • Sign Item 25 of CMS-1500 form
    • Sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles
    • Authorize an employee (e.g., nurse, secretary) to enter physician's signature in Item 25 of CMS-1500 form
      • Manually
      • By stamp-facsimile or block letters
      • By computer
    • Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, physician's signature in Item 25 of CMS-1500 form, followed by 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, agent may simply enter physician's signature
  2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for services of physician, entity may:
    • In an unassigned claim, provide an itemized bill on its letterhead-no signature necessary. A CMS-1500 form on which name or identification code of billing entity has been stamped or preprinted in Item 8 is equivalent of reassignee's letterhead
    • Have authorized official sign in Item 25 of CMS-1500 form
    • Have authorized official sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles
    • Have authorized employee, e.g., a secretary, enter authorized official's signature in Item 25 of CMS-1500 form
    • Have nonemployee agent enter authorized official's signature in Item 25 of CMS-1500 form

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Last Updated Thu, 19 Dec 2019 10:10:53 +0000