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Who May File an Appeal?

Any of the following persons or entities is considered a party to an appeal of a claim for items or services payable under Medicare and, therefore, may appeal the initial claim determination and any subsequent appeal decisions:

  • Beneficiary
  • Participating physician or supplier (one who has agreed to accept assignment on all claims)
  • Nonparticipating physician or supplier who has accepted assignment for a specific service or claim
  • Nonparticipating physician not accepting assignment, but responsible for refunding the beneficiary under Section 1842(1)(1) of the Social Security Act
  • Nonparticipating supplier of durable medical equipment responsible for refunding the beneficiary under Section 1834(a)(18) of the Social Security Act
  • Supplier of medical equipment and supplies furnishing items to a beneficiary on a nonassigned basis and responsible for refunding the beneficiary under Section 1834(j)(4) of the Social Security Act
  • An applicable plan (liability insurance including self-insurance, no-fault insurance, or a workers’compensation law or plan) with respect to recovery of a claim if Medicare is pursuing recovery directly from the applicable plan.
  • A Medicaid state agency, or party authorized to act on behalf of the state
  • Any individual whose rights with respect to the particular claim being reviewed may be affected by such review and any other individual whose rights with respect to supplementary medical insurance benefits may be prejudiced by the decision

Requests for an appeal submitted by someone other than those listed will be dismissed.

Appointment of Representative

A party may appoint any individual, including an attorney, to act as his/her representative. Although some parties may pursue a claim or an appeal on his/her 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 party during both the processing and appeal of a claim or claims. The appointment of a representative is valid for one year from either the date signed by the party making the appointment, or the date the appointment is accepted by the representative, whichever is later.

Who May Be a Representative

When Is an Appointment Not Necessary?

When Is an Appointment Not Necessary?

Required Elements

Required Elements

What if the Appointment of Representation Form Is Incomplete or Defective?

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FQHC Mailing Address:

National Government Services, Inc.

Attn: Appeals

P.O. Box 6474 | Indianapolis, IN 46206-6474

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