Who May File an Appeal?

Any individual may be appointed to act as a representative unless he/she is disqualified or suspended from acting as a representative in proceedings before the 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
• Surrogate decision maker for an incapacitated beneficiary
• Attorney
• Congressional staff members
• Member of a beneficiary advocacy group

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 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 his/her acceptance of being appointed as representative.

Attorney Representatives

If the person representing the party is an attorney, the attorney is not required to sign the Appointment of Representative form or a written statement. However, if it is not evident that the individual representing the party is an attorney, a business card, letterhead, or written statement is required.

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.

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.

The following information must be included on an Appointment of Representative (CMS-1696) form or written statement:

• Name, address, phone number of party (i.e., the beneficiary, physician, or other supplier)
• Medicare Beneficiary Identifier, when the party making the appointment is a beneficiary
• Medicare physician or supplier number, when the party making the appointment is a physician or other supplier
• Name, address, and phone number of the individual being appointed as representative
• A statement that the party (i.e., the beneficiary, the physician, or other supplier) is authorizing the representative to act on her/his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider of services)
• Signature of the party making the appointment and the date signed
• Signature of the individual being appointed as representative, accompanied by a statement that he/she accepts the appointment, and the date signed; however, if the individual being appointed as representative is an attorney, the attorney does not need to accept the appointment in writing
• Prohibition against charging a fee for representation: a physician or other supplier that furnished items or services to a beneficiary may represent that beneficiary on his/her claim or appeal involving those items or services. However, the physician or other supplier may not charge the beneficiary a fee for representation in this situation. Further, the physician or other supplier being appointed as representative must acknowledge that he/she will not charge the beneficiary a fee for such representation. The physician or other supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.
• Waiver of right to payment from the beneficiary for the items or services at issue: for beneficiary appeals involving the denial of the claim on the basis of Section1862(a)(1) or (a)(9), or Section 1879(g) of the Act, and where a limitation on liability determination made under section 1879 of the Act determined that both the beneficiary and the physician or other supplier, knew or could reasonably have been expected to know, that the item or service would not be covered, and where the physician or other supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the physician or other supplier must waive, in writing, any right to payment from the beneficiary for the items or services at issue (including coinsurance and deductibles). The physician or other supplier representative does this by including a statement to this effect on the form or written statement, and then signs and dates it.

The prohibition against charging a fee for representation, and the waiver of right to payment from the beneficiary for the items or services at issue, do not apply in those situations in which the physician or other supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e., where the physician or other supplier is not also acting as representative for the beneficiary), or where the items or services at issue were not provided by the physician or supplier representative.

When to Submit the Appointment

A representative, beneficiary, or other party may submit the completed appointment at the time such person files a request for appeal or at any time during the processing of the appeal.

Note: A completed Appointment of Representative (CMS-1696) form or written statement, or a copy of such form or statement, must be submitted with each appeal request.

Validity of an Appointment Over Time

A new Appointment of Representative (CMS-1696) form or written statement does not need to be executed each time an appeal is filed by the same representative who is representing the same party. For the administrative convenience of both the party making the appointment and the representative, the representative may maintain a completed appointment on file and then submit a copy with each new appeal request.

The following information must be included on an Appointment of Representative (CMS-1696) form or written statement:

• Name, address, phone number of party (i.e., the beneficiary, facility, physician, or other supplier)
• Medicare Beneficiary Identifier, when the party making the appointment is a beneficiary
• Medicare NPI number, when the party making the appointment is a facility, physician or other supplier
• Name, address, and phone number of the individual being appointed as representative
• A statement that the party is authorizing the representative to act on her/his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider of services)
• Signature of the party making the appointment and the date signed
• Signature of the individual being appointed as representative, accompanied by a statement that they accepts the appointment, and the date signed
• Prohibition against charging a fee for representation: a physician or other supplier that furnished items or services to a beneficiary may represent that beneficiary on their claim or appeal involving those items or services. However, the physician or other supplier may not charge the beneficiary a fee for representation in this situation. Further, the physician or other supplier being appointed as representative must acknowledge that they will not charge the beneficiary a fee for such representation. The physician or other supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.
• Waiver of right to payment from the beneficiary for the items or services at issue: for beneficiary appeals involving the denial of the claim on the basis of Section1862(a)(1) or (a)(9), or Section 1879(g) of the Act, and where a limitation on liability determination made under section 1879 of the Act determined that both the beneficiary and the physician or other supplier, knew or could reasonably have been expected to know, that the item or service would not be covered, and where the physician or other supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the physician or other supplier must waive, in writing, any right to payment from the beneficiary for the items or services at issue (including coinsurance and deductibles). The physician or other supplier representative does this by including a statement to this effect on the form or written statement, and then signs and dates it.
• The prohibition against charging a fee for representation, and the waiver of right to payment from the beneficiary for the items or services at issue, do not apply in those situations in which the physician or other supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e., where the physician or other supplier is not also acting as representative for the beneficiary), or where the items or services at issue were not provided by the physician or supplier representative.

When to Submit the Appointment

A representative, beneficiary, or other party may submit the completed appointment at the time such person files a request for appeal or at any time during the processing of the appeal.

Note: A completed Appointment of Representative (CMS-1696) form or written statement, or a copy of such form or statement, must be submitted with each appeal request.

Validity of an Appointment over Time

A new Appointment of Representative (CMS-1696) form or written statement does not need to be executed each time an appeal is filed by the same representative who is representing the same party. For the administrative convenience of both the party making the appointment and the representative, the representative may maintain a completed appointment on file and then submit a copy with each new appeal request.

What Rights Does a Representative Have?

A representative has all the same rights as the beneficiary they are representing. The representative may submit arguments, evidence or other materials on behalf of the appellant. The representative may obtain information from the MAC regarding the claim or appeal at issue. The representative and the beneficiary may participate at all levels of the appeal. Any notice, acknowledgement, or determination letter must be sent to both the party and the representative. The appellant is the addressee with the representative receiving a copy of the notice.

Responsibilities of the Representative

• The appointment of representative by a party must be made freely and without coercion. The MAC should assume that a representative is not making false or misleading statements, representations, or claims about any material fact affecting any person’s rights.
• The representative will have access to confidential information. The MAC must assume that the representative will not disclose personal information except as necessary to pursue the appeal. The representative should not disclose any personal or confidential medical information outside of the appeals process.
• A provider or supplier may not charge the beneficiary a fee to represent them. A statement to this effect should be included in the right to represent form or the written form.
• A representative should keep a completed appointment on file and submit a copy with each claim appealed.

If the Represented Party is the Beneficiary

There are three different scenarios:

1. If an individual is attempting to represent a beneficiary and has submitted an incomplete or defective form, the MAC must advise the individual how to complete the appointment. The MAC allows 14-calendar days for a corrected appointment to be submitted. If at the end of the 14 days, no completed form is submitted, the MAC should complete the appeal and notify the beneficiary and any other party to the appeal—but not an unauthorized representative.
2. If the MAC has evidence (a signed MSN) that the beneficiary knew of or approved of the submission of the request for a redetermination and the representative does not send a right to representation form, no action is necessary. The appeal will be entered as a beneficiary request, and the MAC should complete the appeal and notify the beneficiary and any other party to the appeal—but not an unauthorized representative.
3. If the MAC has evidence that the appointment was not submitted at the request of the beneficiary, the MAC will not conduct the appeal unless confirmation is received from the beneficiary that the request was submitted with their approval. In this case, an Appointment of Representative Form (CMS-1696 form) form will be requested with the acknowledgement.

If the Represented Party is the Provider

The MAC notifies both the person submitting the appointment and the provider that the appointment is incomplete. The MAC allows 14 days for the corrected/completed appointment to be submitted. It can be submitted by mail or fax. If the form is not corrected/completed after the 14 days, the appeal request is dismissed, and the provider and the person submitting the appointment will be notified.

Is a Power of Attorney Acceptable as a Valid Appointment?

A MAC treats a power of attorney as a valid appointment if all the required elements are present and the power of attorney authorizes the designated person to conduct the beneficiary’s affairs. It can be general or very specific but it must at least state the beneficiary’s affairs or the beneficiary’s financial matters.

• A power of attorney is exempt from the one year validity rule.
• A power of attorney may be durable (i.e., surviving after the incapacitation of the beneficiary) or nondurable (i.e., automatically revoked upon the incapacitation of the beneficiary).

What Happens to the Appointment if the Beneficiary Becomes Incapacitated or Dies?

If it is a durable power of attorney that authorizes that designated person to conduct the beneficiary’s affairs or make financial decisions, that representative does not become invalid. If it is a valid appointment or a nondurable appointment, it becomes invalid. The MAC must resolve who has legal authority to act on the behalf of the beneficiary.

Who Can File the Appeal if the Beneficiary is Deceased?

The MAC must obtain proof of one of the following:

• Legal representative of the estate
• A person who has assumed responsibility for settling the beneficiary’s estate (a will or probate court document)

Note: Acceptable legal documentation may vary according to each state. If this is not sent with the appeal request, the MAC must request it. The MAC allows 14 days to obtain this information. If the documentation is not received after 14 days, the MAC must dismiss the appeal request. If the documentation comes in after the allotted time, the MAC must consider good cause for late filing.

What Information can be Disclosed to the Representative?

The representative is entitled to receive only information that the party (beneficiary or appellant) would be entitled to receive (i.e., determination letter) and that which is pertinent to the case/claim to which the representative is being appointed.