Provider signature of Medical claims - electronic claim form
Provider Signatures
This section discusses the various requirements for provider
signatures when filing electronic or hard copy claims.
Medical Claims
The provider's signature on a claim form/medical submission
agreement certifies that the services filed were performed by the provider or
supervised by the provider and were medically necessary.
Individual practitioners (not groups or clinics) may sign a medical claims
submission agreement with Medicaid for the submission of paper claims instead
of signing individual claim forms.
By signing the claim agreement, the provider agrees to keep
any records necessary to enable the provider to perform the following
responsibilities:
• Disclose the extent of services the provider furnishes to
recipients
• Furnish Medicaid, the Secretary of HHS, or the state
Medicaid Fraud Control
Unit, upon request, any information regarding payments
received by the provider for furnishing services
• Certify that the information on the claim is true,
accurate, and complete, and the claim is unpaid
• Affirm the provider understands that the claim will be
paid from federal and state funds, and any falsification or concealment of a
material fact may be prosecuted under federal and state laws
Providers who have a completed Medical Claims Submission
Agreement on file should place the words "Agreement on File" in block
31.
If an agreement is not signed, the individual practitioner
must personally sign theclaim form in the appropriate area or initial the claim
form beside a typewritten or
stamped signature. An individual practitioner's name or
initials may be signed by
another person who has power of attorney from the
practitioner.3
Computer Generated Claim Forms
Computer generated claim forms may be submitted with the
provider's name generated on the form. In which case, the provider’s
handwritten name or initials must accompany the name.
"Agreement on File" may also be printed on
computer generated claim forms in lieu of the provider's signature, if a
Medical Claim Submission Agreement is on file
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