(Medicare Claims Processing Manual)

 The appoint ed representative provide s written noti ce to the  party of the appoint ed representatives intent to delegate to anothe r individua l.  The  notice must in clude the n ame of the designee and the designees acceptance to be  obliga ted and comply with the re quirements or  representation unde r this subpar t.   The party accepts the  designation b y signing a written statement to th at effect.  This si gned statement is not re quired when the  appoint ed representative and designee are attorneys in the  same law firm or organization.  270.1.5 - Duration of Appointment (Rev. 2926, Issued: 04 -11-14, Effective: 07 -14-14, Implementation: 07- 14-14)  An a ppointm ent is c onsidered va lid for 1 year from the  date that the CMS-1696 or  othe r conforming written inst rument contains the  signatures of both the  party and appoint ed representative.  Requiri ng that a new appointm ent be  execut ed on a  yearly basis w ill help ensure that the re is an ongoing r elationship between the  party  and his/he r representative .  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 a compl eted appointm ent instrum ent is sign ed by the party  and t he appoint ed representative).  When initiating a n ew appeal within the one  year time frame, the representative  must file  a copy of the  compl eted appointm ent instrum ent with the  appeal request.  Allowing  the representative to use  the same appointm ent for up to one y ear will h elp reduce the paperwork involve d in representing parties.  The MAC  may also pl ace information a bout a ppointm ent va lidity in provider newsletters, bull etins, e ducation al materials, etc.  The appointm ent remains valid th roughout a ny and all subs equent levels of administra tive appeal on the  claim or  claims a t issue.  Therefore, the representative need not s ecure a new appointm ent wh en proceeding to the  next level of appeal on the  same items, s ervices or claim(s).  This holds t rue regardless of the length of time it ma y take to resolve  the appeal.    270.1.6 - Curing a Defective Appointment of Representative (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  If any of the required elements liste d in 270.1.2 are missin g, the appointm ent of representative f orm is considered d efective.  How a  MAC  handles these situations de pends on the  party attempting to m ake an appointm ent.  W hen the  beneficiary attempts to m ake the appointm ent, the  MAC  provide s assistance to the  beneficiary and representative in securing the appointm ent, based on the  time fra mes set forth be low.  When a provide r or physician or othe r suppli er attempts to ma ke the a ppointm ent, the  MAC  provide s inst ruction on the  proper and tim ely compl etion of  the a ppointm ent.  Where an adjudication time frame applies, the time from the later of the date that a defective appointment of representative was filed or the current appeal request was filed by the prospective appointed representative, to the date when the defect was cured, the party notifies the adjudicator that he or she will proceed with the appeal without a representative, or the 30- day deadline for curing the defect has elapsed with no response, does not count towards the adjudication time frame. The  following provide s guidance on properly respondi ng to a representatives attempt to submit a  request for appeal.   A. M issing or Defective Appoi ntment When a Beneficiary is t he Represented Party  1. Defective Appoi ntment of Representative  When an individua l is a ttempting  to act  as a beneficiarys representative, but submits a n inc ompl ete or defective  appointm ent instr ument, the  MAC  shall advise  the individua l of how to c ompl ete the appointm ent, and sha ll notif y the individua l to su bmit the c ompl eted appointm ent to the  MAC  within 30 calendar da ys.  T he MAC shall ad vise the individual of w hat c orrections are  required to execut e a valid appointm ent and that a decision l etter will not be  sent to the  individual unl ess a valid appointm ent is executed.  Should the  appointm ent inst rument not be  corrected within 30 c alendar da ys, the  MAC  proceeds with p rocessi ng and rendering a  decision on the  appeal, unl ess there is ev idence or information to indi cate the  appeal was not submitt ed at the request of the  beneficiary.  It sends the appeal d ecision to the beneficiary and any other party to the a ppeal, but not to the  individual att empting to a ct as the  beneficiarys representative.  This will e nsure that the beneficiary receives an appeal d ecision w hen it a ppears th at the a ppeal originated with the  beneficiary or was submitte d with the  beneficiarys knowl edge and consent.  When ther e is in formation or  evidence that the appeal re quest and/or  the appointm ent of re presentative instrument w as not s ubmitte d at the request of the beneficiary, the MAC  shall verify the beneficiarys wish es with r egard to the  appeal ( e.g., whe re more than one m ember of the beneficiarys family has submitte d an appeal or is attempting  to act as representative for the beneficiary).  In order to ver ify the wish es of the beneficiary, the MAC  sends a  letter to the  beneficiary explaining  the situation.  The  letter shall advise  the beneficiary that in order to proceed with an appeal, a valid appointment instrument must be submitted within 30 calendar days.  If no response  is receiv ed within 30 calendar days th en the  appointm ent of representative will not be  honore d, and no r edetermin ation w ill be p erform ed.  The MAC shall handle this as an inquiry.   2. Missi ng Appointment of Representative  In cases of appeals filed on be half of the beneficiary, the MAC n eed not de velop a n absent appointm ent of representative if the request for redetermination c learly shows the be neficiary knew of or approved the  submission of  the request for redetermination.  It s ends the  appeal decision to the  beneficiary and any other party  to the  appeal, but not to the  individual atte mpting  to act as the  beneficiarys representative .  This w ill ensure  that the  beneficiary receives an appe al decision w hen it app ears that the  appeal was submitte d with the  beneficiarys know ledge and consent.  When ther e is in formation or  evidence that the appeal re quest filed on behalf of the beneficiary was not submitte d at the request of the beneficiary, the MAC sh all verify the beneficiarys wish es with r egard to the appeal ( e.g., whe re more than one m ember of the beneficiarys family has submitte d an appeal or is attempting  to act as representative for the beneficiary but does not include an appointment instrument ).  In order to ver ify the wish es of the beneficiary, the MAC  sends a  letter to the  beneficiary explaining the situation.  The  letter shall advise  the beneficiary that a valid appointment instrument must be submitted within 30 calendar days in order to process the appeal.  If  no re sponse  is receiv ed within 30 c alendar days, the n the  MAC  does not conduct a  redetermin ation.  The MAC shall handle this as an inquiry.  B. Defective or Missing Appoi ntment When a Provider or Physician, Other Supplier, or Nonbeneficiary is t he Represented Party  1. Defective Appoi ntment of Representative  In cases where the represented party is n ot a beneficiary, the  MAC noti fies both the indi vidual attempting to  be the representative  and the party  of the incompl ete or defective a ppointm ent.  T he MAC explains w hy the appointm ent is d efectiv e, and de scribes the documentation or  missing  information th at is required to c ompl ete the appointm ent.  This m ay be done by telephone  or written noti fication, and the method, time and date of any notification shall be documented in the case file.  A c orrected/compl eted appointm ent may be submitte d to the  MAC  by mail, or at the  MACs disc retion b y facsimile  or (if availabl e) secure  Internet portal.  T he MAC allo ws 30 c alendar d ays for the  correct ed appointm ent instrum ent to be  submitt ed.  Should the  party fail to notify the MAC to proceed with the appeal without a representative, or the appointm ent inst rument is n ot corrected within the  time  limit, t he MAC  dismisses the appeal reque st and sends a dismissal noti ce to the  party  (See 310.6.A.4) .   2. Missi ng Appointment of Representative  If an individua l is a ttempting  to act a s a representative of a party  that is n ot the b eneficiary and fails to include an appointm ent instrument with the  appeal request, the indi vidual l acks the  author ity to act on behalf of the party, and is not e ntitle d to obt ain or recei ve any information r elated to the  appeal.  The MAC shall notify  the individual that no r edetermination w ill be  perform ed until a  valid r equest is r eceived from the  party or a valid appointm ent instrum ent is r esubmitte d with the  redetermination r equest.  T he MAC shall handle  this as an inquiry ( see 310.1.B.5) .  C. Untimely Appeal Request Subm itted With an Incomplete or Defective Appoi ntment  If an untim ely-filed appeal request is submitt ed with an inc ompl ete or defective a ppointm ent instrum ent, the  MAC first d etermin es if good c ause for late  filing ex ists ( See 240 ).  If the MAC finds that good c ause for late filing ex ists, it follows the instr uctions c ontained in 270.1.6, a bove , prior to proceedi ng with the  appeal request.  If the  MAC do es not find good c ause to ex tend the filing time  limit, it d ismisses the r edetermination request.  See 310.6.3 and 310.6. A.3.  D. Un timely Appeal Request Subm itted With a Missi ng Appointment  1. Missi ng Appointment when the Beneficiary is the Party   If an untim ely-filed appe al request is submitte d by an indi vidual atte mpting  to represent a b eneficiary and the  request doe s not inc lude an a ppointm ent instrume nt, the  MAC first d etermin es if good c ause for late filing ex ists (See 240 ).  If the MAC finds that good c ause for late  filing ex ists, it follo ws the instructions c ontaine d in 270.1.6.A.2. prior to proceeding w ith the  appeal request.  If the MAC do es not find good c ause to ex tend the  filing time  limit, it dismiss es the redetermination r equest.  (See 310.6.3 and 310.6.A.3.)   2. Missi ng Appointment When Provider or P hysician, Other Suppl ier, or No nbeneficiary is the Represented Party   As ex plain ed in 270.1.6 .B.2 above , if the  individual la cks the authority to a ct on be half of the  party  and is not e ntitle d to obtain or r eceive any information r elated to the  appeal, do not ma ke a good c ause determination; follow  the instru ctions in 270.1.6.B.2. above .  270.1.7 - Incapacitation or Death of Beneficiary (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)