Appointment of Representative - JA DME

A beneficiary or supplier can appoint any individual to act as his/her representative in requesting an appeal. A representative may be appointed at any time in the appeals process. The appointment of representative is valid for one year from either 1) the date signed by the beneficiary or supplier making the appointment, or 2) the date the appointment is accepted by the representative, whichever is later. A copy of the completed appointment must be submitted with each appeal request.

The appointment can be made by completing the CMS-1696 - Appointment of Representative form; however, an appointment of representative form is not necessary. A written statement containing all the required elements is also acceptable as a valid appointment of representative. The required elements for a written statement are:

• Name, address, phone number of the beneficiary or supplier.
• Medicare number if the party is the beneficiary.
• Medicare supplier number if the party is the supplier.
• Name, address, phone number of the individual being appointed as representative.
• A statement that the party (beneficiary or supplier) is authorizing the representative to act on their behalf for the claims at issue and a statement authorizing disclosure of individually identifiable information to the representative.
• Signature of the party (beneficiary or supplier) making the appointment and the date signed.
• Signature of the individual being appointed as representative, accompanied by a statement that they accept the appointment and the date signed.
• Prohibition Against Charging a Fee for Representation: A supplier that furnished services to a beneficiary may represent them on their claim or appeal involving those services; however, the supplier may not charge the beneficiary a fee for representation. Further, the supplier being appointed as representative must acknowledge that they will not charge the beneficiary a fee for such representation. The supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.

The beneficiary can also transfer his/her appeal rights to his/her health care provider by completing the Transfer of Appeal Rights form.

The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive, and is meant for illustrative purposes only:

• Congressional staff members.
• Family members of a beneficiary.
• Friends or neighbors of a beneficiary.
• Member of a beneficiary advocacy group.
• Member of a provider or supplier advocacy group.
• Attorneys; and
• Physicians or suppliers.

Required AOR Signatures and Timeliness Examples

• Representative must sign AOR form within 30 calendar days of party's signature
• Appointment of Representative form requires two dated signatures
  • Signatures include party to appeal and entity seeking to represent party to appeal
• Signature is valid one year from time of signing
  • If signature dates are not the same, the latest date (must still be timely upon Noridian's receipt of appeal, to be considered valid) will determine the one-year timeliness

*Noridian will consider holidays, weekends, and days the Noridian office is closed, which may impact receipt times.

Resource

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29