July 9, 2019

Medical records submitted for BlueCross BlueShield of South Carolina Medicare Advantage members must include a signed order. The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records (operative reports, orders, test findings, etc.) is to demonstrate that services have been accurately and fully documented, reviewed and authenticated. It also confirms the provider has certified the medical necessity for the service(s) submitted for payment consideration. This requirement is in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines.

There are exceptions to the above requirements: 

• Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
• There are some circumstances for which an order does not need to be signed. For example, orders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100-02 chapter 15, §80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.
• Other regulations and the CMS’ instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed below to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.
• CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.

Please review medical records to ensure the ordering practitioner’s signature is present prior to submitting requested records.

If you have questions about this bulletin please contact Provider Relations and Education by submitting the Provider Education Contact Form or by calling 803-264-4730 and a knowledgeable education specialist will respond.