CMS Pub. 100-04, ch. 1, § 50.1.3

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 provider’s 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 beneficiary’s 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 representative 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 resident’s

name, followed by “P/A,” the administrator’s 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 patient’s 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 described 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 subject to review by the A/B MAC

(A).

The hospital or SNF need not attempt to obtain the patient’s 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 the 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 patient’s signature while he is there.

If it is impractical to obtain the patient’s 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 patient’s 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 Signer’s 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.