(Medicare Claims Processing Manual)

To implement this procedure the provider must incorporate language to the following effect in its records:   Request for Payment   _______________________  NAME OF BENEFICIARY _______________________  Medicare beneficiary identifier  I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in (name of provider).  I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed t o determine these benefits or benefits for related services.   For services furnished to inpatients of a hospital, or SNF, the request is effective for the period of confinement.  For services furnished by an HHA under a plan of treatment the request is effective for the plan of treatment. For other services the request is effective until revoked.  If a patient objects to part of the request for payment, the provider should annotate the statement accordingly.  In using this procedure, the provider undertakes to make the patient signature files available for A/B MAC (A and B) inspection on request.  The A/B MAC (A and B) must make periodic audits of signature files selected on a random basis. The A/B MAC (B) may arrange with the A/B MAC (A) for the latter to perform this function on its behalf for A/B MAC (B) claims submitted by providers.   50.1.3 - Signature on the Request for Payment by Someone Other Than the Patient  (Rev. 2984, Issued: 07- 11-14, Effective: 08 -12-14, Implementation: 08- 12-14)  General   If at all practical the patient should sign the request on the providers records at the start of care, or upon admission for hospital or SNF admissions.  However, where a beneficiary is unable to execute a request for payment because of a mental or physical condition, the request may be executed on his/her behalf by a legal guardian, representative payee (a person designated by the Social Security Administration or other governmental agency to receive an incompetent beneficiarys monthly cash benefits), relative, friend, representative of an institution providing him/her care or support, or of a governmental agency providing assistance.  A physician or supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the enrollee is unable to sign and that there is no other person who could.  For this purpose, an institution providing him/her care includes a long- term care facility, a hospital (whether psychiatric or general), a SNF, and a nursing home.  Only an employee of the institution or agency may be authorized to act as its representat ive to sign claims on behalf of incompetent patients.   The name of the incompetent person should be shown on the signature line of the Request for Medicare Payment (or equivalent authorization retained in the file, followed by by and the signature of the requestor.  The requestor, other than a representative payee, should attach a statement to the Request for Medicare Payment explaining his/her relationship to the beneficiary and the reason the beneficiary cannot sign.  If such a statement is not submitted, A/B MACs must obtain an explanation if other development is needed or if the physician or supplier (or employee) has signed.  Except in such cases, A/B MACs should not delay processing the claim to obtain an explanation.   A/B MACs are permitted to honor an otherwise properly completed and submitted claim signed by the administrator (or other authorized employee) of a nonprofit long- term care facility on behalf of a resident who has given the facility the necessary power of attorney (P/A).  (A long -term care facility, as distinguished from a nursing or other SNF, is an institution that contractually provides room, board, medical, and other necessary services to people who commonly enter and remain there for life, even when in good health.  It may include a skilled nursing unit.)  A/B MACs may assume that the facility has the necessary authority when the administrator enters in the signature space the residents name, followed by P/A, the administrators signature, his title,  and the name of the home.  A signature on behalf of a competent enrollee based on a P/A granted to anyone other than an authorized official of a nonprofit long- term care facility is not acceptable.   NOTE:  The fact that such a request may be honored does not mean that payment can be made to the requestor.   In certain circumstances, it would be impracticable for an individual to sign the request for payment himself because when he is admitted to a hospital or skilled nursing facility or first receives outpatient or home health services, he is unconscious, incompetent, in great pain, or otherwise in such a condition that he should not be asked to transact any business .  In such a situation, his representative payee (i.e., a person designated by the Social Security Administration to receive monthly benefits on the patients behalf), a relative, legal guardian, or a representative of an institution (other than the provider) usually responsible for his care, or a representative of a governmental entity providing welfare assistance, if present at time of admission, should be asked and permitted to sign on his behalf.   A.  Provider Signs Request   If, at the time of admission, the patient cannot be asked to sign the request for payment and there is no person present exercising responsibility for him, an authorized official of the provider may sign the request.  Except in the outpatient case describe d below, where the patient is not physically present, a provider should not routinely sign the request on behalf of any patient.  If experience reveals an unusual frequency of such provider -signed request from a particular provider, the matter will be subj ect to review by the A/B MAC (A).  The hospital or SNF need not attempt to obtain the patients signature where the physician sends a specimen (e.g., blood or urine sample) to a laboratory of a participating hospital or SNF for analysis, the patient does not go to the hospital or SNF, but t he tests are billed through that provider.  The hospital or SNF may sign on behalf of the patient and should note in its records Patient not physically present for tests.  This does not apply in cases in which the patient actually goes to the hospital or SNF laboratory for tests and the provider fails to obtain the patients signature while he is there.  If it is impractical to obtain the patients signature because a home health agency does not make a visit to his home (e.g., the physician certifies that the patient needs a certain item of durable medical equipment but no visits are certified), the agency may furnish the equipment and need not obtain the patients signature.  An agency representative should sign on behalf of the patient and indicate in the provider record Patient not visited.   B.  Patient Dies   If the patient dies before the request for payment is signed, it may be signed by the legal representative of the estate, or by any of the persons or institutions (including an authorized official of the provider) who could have signed it had the patient been alive and incompetent.   A request for payment for inpatient hospital services filed with the hospital may serve as an application for HI entitlement when filed by or on behalf of a live patient, but not  when filed on behalf of a deceased patient.  See 50.1.4.  C.  Need for Explanation of Signers Relationship to Patient   When someone other than the patient signs the request for payment, the signer will submit a brief statement explaining the relationship to the patient and the circumstances which made it impracticable for the patient to sign.  The provider will retain the statement in its files.  The A/B MAC (A) will generally accept such a statement as representing the true facts of the case in the absence of evidence to the contrary.  If development is needed for some other reason, the A/B MAC (A) will ask the provider to furnish the explanation of relationship and circumstances.  However, processing the claim should not ordinarily be delayed to obtain the explanation if nothing else prevents payment.   50.1.4 - Request for Payment as a Claim for HI Entitlement  (Rev. 1, 10- 01-03) A3-3302.6   To become entitled to hospital insurance, an individual must not only be eligible, but must also, prior to his death, apply for such entitlement (or for monthly social security benefits) with the Social Security Administration (SSA).  Even though an individual meets all eligibility requirements, if the necessary application is not filed before death, the individual cannot be entitled to Part A benefits and no payment can be made under the HI program for hospital services.   Occasionally a patient aged 65 or over who is admitted to a hospital, though eligible, has never applied for monthly benefits and has no health insurance card.  In very rare instances the patient may have a card even though the necessary application has not been filed.  To protect the eligible patient, the estate, and the hospital against the possibility that timely application will not be filed with SSA, a written request for  title XVIII payment filed with the hospital may serve as an application for hospital insurance entitlement filed with SSA.  The request must be filed with the hospital prior to the death of the patient.  A prescribed application form properly executed mus t be filed with SSA within six months of the date of SSAs written notice to a proper applicant of the need for such application.  Chapter 2 contains the details of this procedure.   This function of the written request as an informal claim for HI entitlement under certain conditions is distinct from its far more general and basic function as a request that payment may be made on behalf of an entitled individual to the provider.  A request for payment in this latter sense can validly be executed after the death of the entitled individual.  50.1.5 - Refusal by Patient to Request Payment Under the Program  (Rev. 1, 10- 01-03) A3-3302.7   A patient on admission to a hospital or skilled nursing facility may refuse to request Medicare payment and agree to pay for the services out of their own funds or from other insurance.  Such patients may have a philosophical objection to Medicare or may f eel that they will receive better care if they pay for services themselves or they are paid for under some other insurance policy.  The patients impression that another insurer will pay for the services may or may not be correct, as some contracts express ly disclaim liability for services covered under Medicare.  Where the patient refuses to request Medicare payment, the provider should obtain a signed statement of refusal wherever possible. If the patient (or his representative) is unwilling to sign, the provider should record that the patient refused to file a request for payment but was unwilling to sign the statement of refusal.   In any event, there is no provision that requires a patient to have covered services paid for under Medicare if the patient refuses to request payment.  Therefore, a provider may bill an insured patient who positively and voluntarily declines to request Me dicare payment.  However, if such a person subsequently requests payment by Medicare (because another insurance will not pay or for another reason) and requests payment under the health insurance program within the prescribed time limit, the provider must submit a Medicare claim, and refund to the patient any amounts the beneficiary paid in excess of the permissible charges.   Where a patient who has declined to request payment dies, the right to request payment may be exercised by the legal representative of the estate, by any of the persons or institutions mentioned in the second paragraph of 50.1.3, by a person or institution which paid part or all of the bill, or in the event a request could not otherwise be obtained, by an authorized official of the provider.  This permits payment to the provider for services that would not otherwise be paid for and allows a refund to the estate or to a person or institution that paid the bill on behalf of the deceased.   See 70 for filing claims for payment and for associated time limits.   The provider may charge the beneficiary for covered services where the beneficiary refuses to file.   50.1.6 - When Beneficiary Statement is Not Required for Physician/Supplier Claim (Rev. 980, Issued: 06- 14-06, Effective: 10 -01-06, Implementation: 10- 02-06)  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: