(Medicare Claims Processing Manual)

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  A provide r or suppli er that furnishe d items or  services to a  beneficiary may represent that beneficiary on the  beneficiarys claim or  appeal involving those  items or  services.  Ho wever, the provide r or suppli er may not charge the beneficiary a fee for representation in this situ ation. F urther, the provide r or suppli er representative being appoint ed as representative must w aive any fee for such representation.  The  provide r or suppli er representative does this b y compl eting section III of the CMS-1696.  Alt ernatively, the provider or suppli er must i nclude a statement to this effec t on any other conforming  written inst rument be ing used, and must sign and da te the statement.  Waiver of Right to P ayment for the Items or  Services a t Issue  For beneficiary appeals involving a liability  determination unde r 1879 of  the Act where the p rovide r or suppli er that furnishe d the  items or  services a t issue  is also serving as the b eneficiarys representative, the provide r or suppli er must w aive, in w riting, any right to pa yment from the  beneficiary for the items or  services a t issue  (including coinsura nce and de ductibles).  The  provide r or suppli er representative does this by compl eting section IV of the C MS-1696 or  othe r conforming  written inst rument, and must si gn and da te the statement.  The prohibition a gainst c harging a  fee for representation, a nd the  waiver of right to pa yment from the  beneficiary for the items or  services at issu e, do not a pply in those  situations in whi ch the  provide r or suppli er merely submits the  appeal request on be half of the beneficiary or at the b eneficiarys request (i.e., where the provide r or suppli er is not a lso ac ting a s representative for the beneficiary), or where the items or  services at issue  were not pr ovided by the provide r or suppli er when the  provider or suppli er has b een appoint ed as the  beneficiarys representative.  B.  Required Elements for Written Request (if not using the CMS-1696 f orm)  As set forth in 42 C FR 405.910(c) , a w ritten request for an appointm ent of representation must:   1. Be in writing and be  signe d and dated by both the party and the individual  agreeing to be the representative;  2. Provide  a statement appointing the  representative to act on behalf of the party, and author izing the  adjudi cator to release identifiable health information to the a ppoint ed representative;  3. Include a written explanation of  the purpose and scope of the representation;  4. Contain both the  partys and appoint ed representatives name, phon e number, and address;  5. Contain a unique identifier of the party being represented.  If  the party  being represented is the beneficiary, the Me dicare number must  be provi ded.  If the party be ing represented is a provider or suppli er, the N ational  Provider Identifie r numbe r must  be provid ed. (Exception: An applicable plan appointing a representative in an appeal under 42 CFR 405.924(b)(16)  is not required to include a unique identifier) ;  6. Include the appoint ed representatives professional status or  relationship to the  party; and  7. Be filed with the  entity processi ng the partys initi al determination or  appeal.  Providers or suppli ers that are r epresenting a be neficiary and that furnishe d the  items or s ervices at issue  must c omplete a Waiver of F ee for R epresentation .  In addition, if the  appeal involves a liability  determination unde r 1879 of the  Act, the  provider or s uppli er must also c ompl ete a Waiver of P ayment for Items or S ervices at I ssue.  See 270. 1.2.A.4 and 5.  C.  Re voking an Appoi ntment  The party appointi ng a representative may revoke  the appointm ent at any  time  by providi ng a written statement of revocation to the  contractor.  270.1.3 - Whe n and Whe re to Submit the Appoint ment (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A representative, beneficiary, or othe r party may submit the  compl eted appointm ent to the c ontractor at the time such per son f iles a claim or re quest for appea l or at any time during the processi ng of the appeal.  Appointed representatives are responsible for submitting a valid appointment instrument with each new appeal request.  A valid appointment instrument submitted with an appeal request will be included in the appeal case file and is valid for subsequent levels of appeal for the item(s)/service(s)/claims(s) at issue. With each new appeal request, an appointed  representative may choose to send either an original appointment instrument, or a photocopy of the original.  Should a photocopy of the original appointment instrument be submitted with an appeal request, the original appointment instrument must be mainta ined by the representative or the party, and produced upon request.  I f an appeal or othe r motion is f iled by a representative on b ehalf of a party to the a ppeal, but doe s not inc lude an appointm ent, the  contractor  takes the actions speci fied below in 270.1.6 to s ecure the written appointm ent.  If a valid C MS-1696, or  other conforming written inst rument, ha s previous ly been filed with the c ontractor, the representative is encourag ed, but not r equired, to submit a  copy at subs equent levels of a ppeal.  A valid appointment instrument will be included in the case file for subsequent levels of the appeal of the item(s)/service(s)/claim(s) at issue.  Ho wever, if a new appeal for diffe rent items/services/claims is i nitiated during the one year timefra me of the a ppointm ent, a copy of the appointm ent must be  filed with the new  appeal r equest.  If a contractor has received CMS approval for, and is accepting appeals through, the  use of a secure Internet portal/application (See 310.1.B.2.c), contractors should provide instructions to a ppellants using the Internet portal/application on how to submit the appointment instrument when submitting an appeal.  270.1.4 - Rights and Responsibilities of a Repre sentative (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  In representing an appellant bef ore a MAC, t he representative has certain rights and re sponsibiliti es.  A. Au thority of an Appointed Representative  A representative may represent a party in an appeal of a claim.  An a ppoint ed representative ma y, on b ehalf of the party; obtain appeal information a bout the  claim to the  same extent as the p arty, submit e vidence, make statements about f acts and law, and m ake any request, or  give or recei ve, any notice about the appeal proceedings.  When a MAC  takes action or  issues a  redetermination, it sh all send no tice to onl y the a ppoint ed representative.  Notice shall not be  sent to the  party if there is an appoint ed representative.  The MAC  shall send any requests for information or  evidence regarding an appeal only to the  appoint ed representative.  See also, 270.3 f or MSP specific requirements.  B. Responsibilities of an Appoi nted Representative  An a ppoint ed representative must -   Inform the  party of the scope and re sponsibiliti es of the representation;   Inform the  party of the status of  the appeal and the  results of  actions t aken on be half of the  party such as noti fication of  appeal d eterminations, decisions, a nd further appeal rights;   Disclose to a beneficiary any financial risk and liability of a non- assigned claim th at the b eneficiary may have;   Not act c ontrary to the  interest of  the party; and   Compl y with a ll laws and C MS regulations, C MS Rulings, and inst ructions.  The appointm ent of a representative by a party must be  made freely and wi thout c oercion.  T he MAC  should assume  that a representative is not making false or misle ading statements, representations, or  claims about any material fact affecting a ny persons rights.  How ever, if the MAC  has reason to be lieve that the representative is m aking false or misleading statements, re presentations or  claims about a ny material fact affecting any persons rights, it should refe r the m atter to the  Unified Program Integrity Contractor (UPIC), which were formerly known as Zone Program Integrity Contractors .  A representative will h ave access to personal and confidential medical and othe r information a bout a  beneficiary.  The MAC  may assume  that the representative will not dis close personal or confidential information a bout a be neficiary except as necessary to pur sue an appeal on be half of the party represented.  Further, it ma y assume  that a representative is not disclosing any personal or confidential medical or othe r information a bout a  beneficiary(ies) outside  of the appeals process.   Unless oth erwise directed by the party making the appointm ent, the  MAC  need not ke ep the re presented party informed of the purpose of the appointm ent, the  scope of the appointm ent, and exactly when/und er what circumst ances the appointment will be  exercised, sinc e it ma y assume the  representative has taken on this re sponsibili ty.  It is the  responsibility  of the representative to keep the  party informed on the  progress of an appeal.  C. De legation of Appoi ntment by Appoi nted Representative  An a ppoint ed representative may delegate the appointm ent if the following c onditions ar e met;   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 .