About Appeals

Who May File an Appeal?

Table of Contents

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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.

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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.

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When Is an Appointment Not Necessary?

Billing clerks or billing services employed by the provider or supplier to prepare and/or bill the initial claim, process the payments and/or pursue appeals act as the agent of the provider and do not need to be appointed as representative of the provider.

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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):

  • Member of a provider, supplier, or physician group
  • Attorney
  • Congressional staff members
  • Member of a beneficiary or provider 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 must submit a copy with each claim appealed.

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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. In order to constitute a valid appointment, the CMS-1696 or other conforming written statement must contain signatures of the representative and the party. By signing the appointment, the representative indicates their acceptance of being appointed as representative.

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When Is an Appointment Not Necessary?

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.

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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.

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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.

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Required Elements

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)
  • NPI number, when the party making the appointment is a provider
  • 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.

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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.

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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.

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What Rights Does a Representative Have?

A representative has all the same rights as the party they are representing. The representative may submit arguments, evidence or other materials on behalf of the party. The representative may obtain information from the MAC regarding the claim or appeal at issue. The representative may participate at all levels of the appeal. When the MAC takes action or issues a redetermination, it will send notice to only the appointed representative. Notice will not be sent to the party when there is an appointed representative. The MAC will send any requests for information or evidence regarding an appeal to only the appointed representative.

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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.
  • An appointed representative must:
    • Inform the party of the scope and responsibilities of the representation;
    • Inform the party of the status of the appeal and the results of actions taken on behalf of the party such as notification of appeal determinations, decisions, and further appeal rights;
    • Disclose to a beneficiary any financial risk and liability of a non-assigned claim that the beneficiary may have;
    • Not act contrary to the interest of the party; and
    • Comply with all laws and CMS regulations, CMS Rulings and instructions.

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

If the Represented Party is the Provider

The MAC notifies both the person submitting the appointment and the provider that the appointment is incomplete or defective. The MAC allows 30 calendar days for the corrected/completed appointment to be submitted. It can be submitted by mail or fax. If a corrected form is not received after 30 calendar days, or the party fails to notify the MAC they wish to proceed with the appeal without a representative, the appeal request is dismissed, and the party will be notified.

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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.

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