Submission
of this claim constitutes certification that the billing
information as shown on the face hereof is true, accurate and
complete. That the submitter did not knowingly or recklessly
disregard or misrepresent or conceal material facts. The
following certifications or verifications apply where pertinent to
this Bill:
If
third party benefits are indicated, the appropriate assignments
by the insured /beneficiary and signature of the patient or
parent or a legal guardian covering authorization to release
information are on file. Determinations as to the release of
medical and financial information should be guided by the patient
or the patient’s legal representative.
If
patient occupied a private room or required private nursing for
medical necessity, any required certifications are on file.
Physician’s
certifications and re-certifications, if required by contract or
Federal regulations, are on file.
For
Religious Non-Medical facilities, verifications and if necessary
re-certifications of the patient’s need for services are on
file.
Signature
of patient or his representative on certifications, authorization
to release information, and payment request, as required by
Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC
1071 through 1086, 32 CFR 199) and any other applicable contract
regulations, is on file.
The
provider of care submitter acknowledges that the bill is in
conformance with the Civil Rights Act of 1964 as amended.
Records adequately describing services will be maintained and
necessary information will be furnished to such governmental
agencies as required by applicable law.
For
Medicare Purposes: If the patient has indicated that other health
insurance or a state medical assistance agency will pay part of
his/her medical expenses and he/she wants information about
his/her claim released to them upon request, necessary
authorization is on file. The patient’s signature on the
provider’s request to bill Medicare medical and non-medical
information, including employment status, and whether the person
has employer group health insurance which is responsible to pay
for the services for which this Medicare claim is made.
For
Medicaid purposes: The submitter understands that because payment
and satisfaction of this claim will be from Federal and State
funds, any false statements, documents, or concealment of a
material fact are subject to prosecution under applicable Federal
or State Laws.
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9. For TRICARE Purposes:
(a) The
information on the face of this claim is true, accurate and
complete to the best of the submitter’s knowledge and
belief, and services were medically and appropriate for the health
of the patient;
The
patient has represented that by a reported residential address
outside a military medical treatment facility catchment area he
or she does not live within the catchment area of a U.S. Public
Health Service medical facility, or if the patient resides within
a catchment area of such a facility, a copy of Non-Availability
Statement (DD Form 1251) is on file, or the physician has
certified to a medical emergency in any instance where a copy of
a Non-Availability Statement is not on file;
The
patient or the patient’s parent or guardian has responded
directly to the provider’s request to identify all health
insurance coverage, and that all such coverage is identified on
the face of the claim except that coverage which is exclusively
supplemental payments to TRICARE-determined benefits;
The
amount billed to TRICARE has been billed after all such coverage
have been billed and paid excluding Medicaid, and the amount
billed to TRICARE is that remaining claimed against TRICARE
benefits;
The
beneficiary’s cost share has not been waived by consent or
failure to exercise generally accepted billing and collection
efforts; and,
Any
hospital-based physician under contract, the cost of whose
services are allocated in the charges included in this bill, is
not an employee or member of the Uniformed Services. For
purposes of this certification, an employee of the Uniformed
Services is an employee, appointed in civil service (refer to 5
USC 2105), including part-time or intermittent employees, but
excluding contract surgeons or other personal service contracts.
Similarly, member of the Uniformed Services does not apply to
reserve members of the Uniformed Services not on active duty.
Based
on 42 United States Code 1395cc(a)(1)(j) all providers
participating in Medicare must also participate in TRICARE for
inpatient hospital services provided pursuant to admissions to
hospitals occurring on or after January 1, 1987; and
If
TRICARE benefits are to be paid in a participating status, the
submitter of this claim agrees to submit this claim to the
appropriate TRICARE claims processor. The provider of care
submitter also agrees to accept the TRICARE determined reasonable
charge as the total charge for the medical services or supplies
listed on the claim form. The provider of care will accept the
TRICARE-determined reasonable charge even if it is less than the
billed amount, and also agrees to accept the amount paid by
TRICARE combined with the cost-share amount and deductible
amount, if any, paid by or on behalf of the patient as full
payment for the listed medical services or supplies. The provider
of care submitter will not attempt to collect from the patient
(or his or her parent or guardian) amounts over the TRICARE
determined reasonable charge. TRICARE will make any benefits
payable directly to the provider of care, if the provider of care
a participating provider.
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