Appointment of Representative - JA DME
Appointment of Representative
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.
- Attorney Representation: If the person representing the party is an attorney, they are not required to sign the representative form or written statement. However, in order to release individually identifiable beneficiary information to an attorney, the beneficiary must sign and complete an appointment naming the attorney or complete a release of information.
- Power of Attorney: A power of attorney is a valid appointment if it contains all of the required elements of an appointment and it authorizes the designated person to conduct the beneficiary's affairs. This can include authorization to conduct personal and financial matters. It can also be a general authorization or may include very specific authorization to pursue benefits under the Medicare program or government entitlement programs. A power of attorney that authorizes the designated person to make health care or medical care decisions alone is not a valid appointment.
- Deceased Beneficiary: If the beneficiary is deceased, the legal representative of the estate may file the appeal request. If there is no legal representative, it may also be filed by any person who has assumed responsibility for settling the decedent's estate. In this situation, there must be proof that the person has assumed responsibility for settling the estate. This proof may be a copy of the will or probate court document.
- Release of Beneficiary Information to Representative: The beneficiary's information cannot be released without their explicit written authorization. In accordance with the Privacy Act, the beneficiary must (1) complete and sign an appointment of representative form naming an individual as their representative, or (2) complete and sign an authorization form explicitly allowing the release of their claim information to the representative.
Filing on Behalf of Beneficiary
An appointment of representative form is not needed if the request for redetermination clearly shows the beneficiary knew of or approved the submission of the request for redetermination (e.g., the request is submitted with the beneficiary's Medicare Summary Notice (MSN) or with a written authorization from the beneficiary). People who often act on behalf of a beneficiary in filing a redetermination request include, but are not limited to: the spouse, parent, daughter or son, sister or brother, or neighbor/friend.
Beneficiary advocacy groups, suppliers, doctors, and Members of Congress may also submit a request for redetermination on behalf of a beneficiary. These requests will be accepted if the request for redetermination clearly shows the beneficiary knew of or approved the submission. In absence of the beneficiary's clear knowledge or approval, an appointment of representative form or written statement is required.
Last Updated Wed, 31 Jan 2018 11:05:55 +0000