TN 1 (07-87)

GN 02335.020 Services Not Paid For--Who May Claim Payment

A. Part A

When the inpatient services listed have not been paid for, no disposition of the underpayment may be made. If such services are paid for at a later date, the underpayment may be paid under the instructions in GN 02335.025ff.

B. Part B

1. Beneficiary Executed Assignment

An assignment made by a beneficiary continues to be effective after his death. Payment may be made on an assigned bill to the physician, supplier, or provider even though the beneficiary has died.

2. Beneficiary did not Execute Assignment

Payment may be made to the physician (or supplier or provider) provided he agrees to accept the reasonable charge (as determined by the carrier) as the full charge. If the physician does not agree to accept the reasonable charge as his full charge, payment may be made on the basis of an unpaid bill to the person who has agreed to assume a legal obligation to pay the physician or supplier for the services and files a request for payment.

C. DO Actions When the Bill is not Paid

Inform the inquirer of the conditions under which Medicare underpayments may be made on an unpaid bill. If the inquirer appears capable and he decides to request the payment, provide him with the necessary claims Form CMS-1490S (or CMS-1450) and an explanation of how the form should be completed. Although it is not necessary for anyone to authorize assignment, complete the identifying information at the top of the form. The bottom part of the form showing services provided the beneficiary should be completed by the physician, supplier, or provider. If the DO decided to develop the claim, follow the instructions in HI 01205.005 for contacting a physician, supplier, or provider.

A physician (or supplier) may signify his agreement to accept the reasonable charge determination by checking the “accept assignment” item on FormCMS-1500 and signing the form, or by submitting a separate signed statement to this effect. The provider may write its agreement in the remarks sections of the CMS-1450 (Inpatient and/or Outpatient Billing). An oral agreement is not sufficient. It is not necessary to obtain the signature of the legal representative of the beneficiary's estate or of any other person in order for payment to be made to the physician, supplier, or provider on an unpaid bill.

If the physician will not accept direct payment, inform the claimant that an individual who wishes to claim benefits for services rendered a deceased beneficiary where the bill has not been paid must submit the following documents:

  1. A signed statement which reads as follows:

    • “I have assumed the legal obligation to pay (Name of physician) for services furnished (Name of deceased beneficiary) on (Date). I hereby claim any Medicare benefits due for these services.”

  2. A completed Form CMS-1490S (Patient's Request for Medicare Payment), or if the physician completed the form, a CMS-l500 (Health Insurance Claim Form), signed by the person claiming the benefits in the space provided for the signature of the patient.

  3. A signed statement from the physician, e.g., on the Form CMS-1500, which signifies the physician's refusal to accept assignment, and

  4. An itemized bill which identifies the claimant as the person to whom the physician looks for payment. If the claimant is the legal representative of the estate, a bill addressed to the estate, or a bill addressed to the beneficiary with indication that the beneficiary is deceased satisfies this requirement.

When the claimant has submitted the above documents, send the claim to the carrier.

The signed statement by the physician refusing to accept assignment is needed because the law requires that the physician be given the first opportunity to claim the payment when the bill is unpaid. He may do so at any time before payment is made to a person who assumed a legal obligation to pay the bill. However, once payment is issued to such a person, the government has no further obligation with respect to the services involved and the physician can, therefore, no longer qualify for payment.

D. Physician Deceased

1. Assigned Claim

If the physician died before an SMI payment due him was completed, payment of the amount due (including the amount of any unnegotiated checks) may be made only to the legal representative of the physician's estate whether or not the enrollee survives. The physician's legal representative need only report the physician's death to the carrier, submit a