(Medicare Claims Processing Manual)

(a) The claims w ere pending before the QIC in conjunc tion with the  same request for reconside ration;  (b) The appellant(s) requests aggregation of  the claims to the  ALJ level in the  same re quest for escalation; a nd  (c) The ALJ determines that the claims th at a single appellant seeks to a ggregate involve the  delivery of simila r or related services, or  the claims th at multiple  appellants seek to a ggregate involve  common issue s of law and fact.  Part A a nd Part B claims may be combine d to m eet the  AIC requirements.  When the  appellant(s) seeks to a ggregate claims i n a request for an ALJ hearing, the appellant(s) must -  (a) Specify all of the claims the  appellant(s) seeks to aggregate; and  (b) State why the appellant(s) believes that the claims involve  common is sues of law and fact or  delivery of simila r or related services.  260 - Parties to an Appeal  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  Any of the persons/entities referenced in 210 are parties to an appeal of a  claim for items or services payable under Part A or Part B and, therefore, may appeal the initial claim determination and any subsequent administrative appeal determinations or decisions made on all claims for items or services (assuming other requirement s, such as filing within prescribed time limits are met).   270 - Appointment of Representative  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  NOTE: See also S ection 270.3,  Medicare Secon dary Payer (MSP) Specific Limita tions or Additiona l Requirements w ith R espect to the  Appointm ent of Representatives.  270.1 - Appointment of Representative - Introduction  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  A party may appoint a ny individua l, including an attorney, to a ct as his/h er representative in dealin gs with the MAC.  Althoug h some  parties may pursue a claim or  an appeal on the ir own, other s will re ly upon the  assistance and expertise of other s.  A r epresentative may help the p arty during the processing  of a claim or  claims, a nd/or  any subsequent appeal.  ( See 270.1.8 f or details r egarding dis closure  of indi vidually  identifiable  beneficiary information.)   The a ppointm ent of a representative is valid for one year from the  date signed by both the  party and the  appoint ed representative (see 270.1.5 b elow).  NOTE:   The appointm ent remains valid for any subsequent levels of appeal on the  item/service in question unl ess the  beneficiary specifically withd raws the  representatives author ity.   New appeals m ay be initiated in w riting b y the representative within the  one year timefra me unless the  beneficiary provides a w ritten stat ement of r evocation  of the r epresentative s authori ty.  Appeals for oth er claims may  be initiate d utilizing  an ex isting appointm ent instrum ent within one ye ar of the effective  date of the  appointm ent (i.e., the date the appointm ent instrum ent is sign ed by the  party  and the  representative ).  To initi ate a new appeal within the  one year time frame, the representative must f ile a copy of the completed appointm ent inst rument with the  appeal re quest.  270.1.1 - Who May Be an Appointed or Authorized Representative (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Any individua l may be appoint ed to act a s a representative unless he/she is disqua lified, suspe nded, or otherwise prohibit ed by law from a cting as a representative in pr oceedi ngs before HH S, or in entitle ment appeals, be fore SSA.   A MAC  should not accept a n appointm ent of representative if it has evidence that the a ppointm ent of representative should not be  honor ed.  It should noti fy the party attempting  to be re presented and the  individual attempting  to represent the  party that the appointm ent will not be honore d.  A spe cific individua l must be  named as the representative.  An or ganization or  entity may not be  named as a representative, but rather a specific member of that organization or  entity must be  named.  This e nsures that confidential beneficiary information is released onl y to the individua l so na med.  A provide r or suppli er who files an appeal request on be half of a beneficiary is not, b y virtue of filing the appeal, a  representative of the beneficiary.  To act as the beneficiarys representative, the provide r or suppli er must execute  a valid appointm ent as d escribed in this s ection.   If the requestor is the  beneficiarys legal guardian, surrogate decision -maker for an inc apacita ted be neficiary, an SSA -appointed representative  payee (See IOM Pub. 10 0-01, C hapter 6, 10.K . for information r egarding SSA rep payees), or is oth erwise author ized unde r State law, no a ppointm ent is n ecessa ry, and the  requestor is considered an au thorized representative.  All MACs shall do cument the  representative s authority to a ct on be half of the  beneficiary in the  case fil e.  (See 270. 1.7 for information on po wer of attorn ey.)  NOTE:  Billing  clerks or  billing  services employed by the provide r or supplier to pre pare and/or bill the  initia l claim, p rocess the  payments, a nd/or  pursue appeals act a s the agent of the provider or suppli er and do not ne ed to be  appoint ed as representative of the provide r/suppli er.  Include e vidence in the  case  file if the physician or othe r suppli er employs a billing c lerk or billing s ervice (a screen print showing that payment is made to the  billing  clerk or billing  service is su fficient.)  If the billing c lerk/billing  service is not authorized to receive  payment, but is a uthor ized to pr ocess p ayments and/or  pursue appeals, in clude evidence in the case file.  If the a greem ent is on f ile, make a notation in the  case file where the agreement can b e located.  (See the M edicare General Information, Eli gibilit y, and Ent itlement M anual, whi ch allows p ayment to be made to an agent who f urnishe s billing  or collection s ervices.)  The following is a list of  the types of individua ls who could be  appoint ed to act a s representative f or a party to an appeal.  This list is not e xhaustiv e, and is m eant for illust rative purposes onl y:   Congression al staff members;   Family members of a beneficiary;   Friends or  neighbors of a beneficiary;   Member of a beneficiary advoc acy group;   Member of a provide r or suppli er advoc acy group;   Attorneys; and   Physicians or  suppli ers.  270.1.2 - How to Make and Revoke an Appointment (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The party making the appointm ent and the  indiv idual accepting the appointment must e ither compl ete an appointm ent of representative form (CMS-1696)  or use a conforming  written inst rument (see subs ection B below, f or required elements of  written inst ruments).  A p arty may appoint a  representative to assist w ith filing a c laim, or a t any time during the course of an appeal.  In order to constitute a valid appointment, the CMS -1696 or other conforming written instrument must contain signatures of the representative and the party. By signing the appointm ent, the  representative indicates his/h er acceptance of being a ppoint ed as representative.  The form C MS-1696 c an be  found at: http://www.c ms.gov/ Medicare/CMS-Forms/CMS-Forms/ CMS-Forms -Items/CMS01220 7.html   All signatures may be handwritten or electronic, digital, and/or digitized.  Electronic, digital, and/or digitized signatures are acceptable for appointment of representative instruments submitted via mail, facsimile, or a CMS -approved secure Internet port al/application.   CMS permits the use of a rubber stamp in lieu of a handwritten signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his or her inability to sign their signature due to their disability.  By affixing the rubber stamp, the person is certifying that they have reviewed the document.   A.  Co mpleting a Valid Appoi ntment of Representative (Form CMS-1696)   The CMS-1696 is a vailable for the convenience of the beneficiary or any other party to use  when appointing a representative.  Followi ng are instructions f or compl eting the form.  1. The name of the party making the appointm ent must be  clearly legible.  If the party be ing represented is the  beneficiary, the  Medicare numbe r must be  provided.  If the party be ing represented is a provider or suppli er, the  National Pro vider Identifie r numbe r must be  provided.  If the party being represented is an applicable plan in an appeal under 42 CFR 405.924(b)(16) , the space may be left blank. A Medicare number is required only when the beneficiary is the party appointing a representative.   2.  C ompleting Section I  Appointm ent of Representative- The party making the appointment includes their signature, address, and phone  numbe r.  If the party that wishes to appoint a representative is a beneficiary, then on ly the beneficiary or the b eneficiarys legal guardian may sign.  If the p arty making the appoint ment is the  provider or suppli er, the provider or suppli er (or person authorized to act on behalf of the provider or supplier) must si gn the form and compl ete this s ection.  The date the  party signs the  form must be  included.  3.  C ompleting Section II   Acceptance of Appointm ent- A sp ecific individua l must be  named to act as representative in the  first line  of this s ection; a  party may not a ppoint a n organization or  group to act as representative.  The  name of the individua l appoint ed as representative must a lways be compl eted, and his/he r relationship to the  party entered.  T he individua l being a ppoint ed signs the form with a signature, da tes and compl etes the rest of this s ection.   4.  C ompleting Section III   Waiver of Fee for Representation- This s ection must be c ompl eted wh en the beneficiary is appointing a  provide r or suppli er as representative, and the pr ovide r or suppli er being appoint ed has f urnished the  items or  services that are the subj ect of  the appeal.  5.  C ompleting Section IV   Waiver of Payment for Items or  Services at Issue  This s ection must be  compl eted wh en the  beneficiary is appointing a provider or suppli er who f urnishe d the  items or  services th at are the subj ect of the appeal and the  appeal involve s issu es described in 187 9(a)(2 ) of the Act (limitation on liability) .  If any of the required el ements liste d above  are missing from the  appointm ent, or are determined to be invalid (e.g., the signatures do not meet the requirements of this section), the  appointment is considered defective.  See 270.1.6 for additional information on processing appe als w ith an in complete or in valid appointm ent.  Prohibition A gainst C harging a Fee for Representation