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Thread: Signed Documentation

  1. #1

    Question Signed Documentation

    AAPC: Back to School
    I do the billing at a Federally Qualified Health Center and a question was raised regarding submitting claims to insurance (Medicaid, Medicare & Third Party) when the electronic medical record has not been signed by the rendering provider.

    Can we submit claims to insurance companies if the note is not signed off by the provider? Or should we wait until that note is signed prior to submitting claims?

    Thank You, Lori

  2. #2
    Join Date
    Apr 2007


    Our office ALWAYS waits until the dictation is signed off by the rendering provider!! The provider needs to review if there are any spelling errors, diagnosis errors, etc.

  3. #3


    I agree with the previous poster. You should have your documentation reviewed and signed prior to sending in the claim. The insurance company may request documentation to accompany the claim.

  4. #4


    Thank you for your responses. I know it is good practice to submit claims once documentation has been signed, but I am wondering if it is policy of insurance carriers? Has anyone heard of this?


  5. #5


    Yes. Most carriers have some sort of policy addressing documentation. It is also in the Medicare Program Integrity Manual, Chapter 3.

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