All point about Signature on File filed box 12 on CMS 1500


Beneficiary Signature Requirements


Medicare requires the signature of the beneficiary, or that of his or her representative, for each date of transport, for both the purpose of accepting assignment and submitting a claim to Medicare. If the beneficiary is unable to sign because of death or a mental or physical condition, the following individuals may sign the claim on behalf of the beneficiary:

The beneficiary’s legal guardian

A relative or other person who receives social security or governmental benefits on behalf of the beneficiary

A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his or her affairs

A representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services or assistance to the beneficiary

A representative of the provider or of the non-participating hospital claiming payment for services it has furnished if the provider or non-participating hospital is unable to have the claim signed by any of the authorized individuals (see the four bullets above) after making reasonable efforts to locate and obtain one of these signatures

A representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport. In this circumstance, ambulance suppliers may submit a claim to Medicare if the following documentation is obtained and maintained for at least four years from the from the date of service for each date of transport:

A contemporaneous statement, which is signed by an ambulance employee present during the trip to the receiving facility that includes:

the date and time of the transport

why the beneficiary was physically or mentally incapable of signing

no legally authorized person was available or willing to sign the claim on behalf of the beneficiary; and

the name and location of the facility that received the beneficiary

AND

Signed statement from the receiving facility indicating that:

the name of the beneficiary; and

the date and time the beneficiary was received

OR



one of the following secondary forms of verification from the receiving facility:

the signed patient care/trip report

the hospital registration/admission sheet

the patient's medical record

the hospital log

other internal hospital records

A provider/supplier (or his employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person to sign.

Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, may obtain this signature any time prior to submitting the claim to Medicare for payment.

If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signatures, then the ambulance provider/supplier may not bill Medicare, but may bill the beneficiary (or his/her estate) for the full charge of the ambulance items and services furnished. If, after seeing the bill, the beneficiary/representative decides to have Medicare pay for these items and services, then a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period.


These requirements apply to both emergent and non-emergent ambulance transports.



Signature-on-File Requirements

When a TRICARE beneficiary has signed a Release of Information statement, you should indicate “signature on file” in Box 12 of the CMS-1500. A new signature is required every year for professional claims submitted on a CMS-1500 and for every admission for claims submitted on a UB-04.


If the beneficiary is under age 18, the parent or legal guardian should sign the claim. However, a beneficiary under the age of 18 may sign the claim form if the beneficiary is (or was) the spouse of an
active duty service member (ADSM) or retiree, or if the services are related to venereal disease, drug or alcohol abuse, or abortion


In situations when a beneficiary is mentally incompetent or physically incapable, the person signing should either be the legal guardian or, in the absence of a legal guardian, a spouse or
parent of the beneficiary. See the Important Provider Information section of this handbook
for more information about the release of patient information.


If the beneficiary is deceased, and you do not have a valid signature-on-file agreement, you
must submit one of the following: 

A claim form signed by the legal representative of the estate.
Documentation accompanying the claim form to show the person signing is the
legally appointed representative.
If no legal representative has been appointed, the parent, spouse, or next of kin may sign
the claim form. 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.
In the event there is no spouse, parent, or guardian to sign the claim form, the claim
must be signed by the surviving next of kin or a legally appointed representative (indicate
relationship to beneficiary)

When there is no spouse, parent, guardian, next of kin, or legal representative to sign the
claim form for a deceased beneficiary, payment may be made to the provider in accordance
with state law and TriWest corporate policy.

Signatures from the following individuals are not acceptable as beneficiary signatures:
A provider or an employee of an institution rendering care
An employee of an entity submitting a claim on behalf of a beneficiary, unless such employee is
the beneficiary’s parent, legal guardian, or spouse Claims submitted for diagnostic tests, test interpretations, or other similar services do not require the beneficiary’s signature. When submitting
these claims, you must indicate “patient not present” on the claim form.

TRICARE randomly reviews claims to help ensure that signature-on-file requirements are being followed.



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