If the requestor is the beneficiary’s legal guardian, surrogate decision maker for an incapacitated beneficiary, an SSA-appointed representative payee, or is otherwise authorized under state law, no appointment is necessary, and the requestor is considered an authorized representative.
Who May Be a Representative
Any individual may be appointed to act as a representative unless they are disqualified or suspended from acting as a representative in proceedings before CMS or is otherwise prohibited by law.
Possible representatives may include (but are not limited to):
- Family member of the beneficiary
- Friend or neighbor of the beneficiary
- Member of a provider, supplier, or physician group
- Attorney
- Congressional staff members
- Member of a beneficiary or provider advocacy group
- Member of an Consultant group assisting a provider
A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is only released to the individual so named.
A physician or other supplier who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative of the beneficiary. To act as the beneficiary’s representative, the physician or other supplier must meet the criteria set forth in this section.
A representative should keep a completed Appointment of Representative (CMS-1696) form on file and submit a copy with each claim appealed.
Note: Billing clerks or billing services employed by the provider, physician or supplier to prepare and/or bill the initial claim, process the payments, and/or pursue appeals act as the agent of the physician or other supplier and do not need to be appointed as representative of the physician/supplier.
How to Make and Revoke an Appointment
The party making the appointment and the individual accepting the appointment must either complete an Appointment of Representative (CMS-1696) form or submit a written statement. A party may appoint a representative at any time during the course of an appeal. The representative must sign the Appointment of Representative (CMS-1696) form or written statement within 30 calendar days of the date the beneficiary or other party signs in order for the appointment to be valid. By signing the appointment, the representative indicates their acceptance of being appointed as representative.