A person/supplier/physician who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative. The Medicare beneficiary may appoint any individual, including an attorney, to act as his/her representative in dealings with Medicare contractors. Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the beneficiary during the processing of a claim or claims, and/or any subsequent appeal. ( Refer to the Centers for Medicare & Medicaid Services [CMS] Internet-Only Manual [IOM] Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 270.1.10 for information on disclosing information to third parties.) The appointment of a representative is valid for one year from the date signed by both the party and the appointed representative.

To act as the beneficiary’s representative, a person/supplier/physician must submit a properly executed appointment of representative. The following information must be included on an appointment of representative form or written statement:

• The name, address, and phone number of the individual.
• The individual’s Medicare number when the party making the appointment is the beneficiary.
• A specific individual must be named as the representative. An organization or entity may not be named as the representative, but rather a specific member of that organization or entity must be named. The representative must sign and date the form and list his/her name, address and phone number. A statement that he/she accepts the appointment needs to be included.
• A statement that the party authorizes the representative to act on her or his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative.
• The signature of the party making the appointment and the date signed.

Note: A representative must sign the Appointment of Representative Form (CMS-1696) within 30-calendar days of the party’s signature.

The appointment of representative is valid for one year from either: (1) The date signed by the party making the appointment, or (2) The date the appointment is accepted by the representative—whichever is later.

The appointment remains valid for any subsequent levels of appeal on the claim/service in question unless the beneficiary specifically withdraws the representative’s authority. However, if during an appeal the appointment of representative expires, a new Appointment of Representative Form (CMS-1696) is necessary.