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