(Medicare Claims Processing Manual)

This w aiver remains va lid unl ess the  transfer is revoke d by the beneficiary as described in subs ection D, below.  C. Du ration of a Valid  Transfer of Appeal Rig hts  Unless revoke d, the transfer of appeal  rights is v alid for all levels of the appeal p rocess including judi cial review, even in the  event of the death of  the beneficiary.  D. Re voking a T ransfer of Appeal Rig hts  The party assigning the ir app eal rights m ay revoke the transfer of appeal  rights b y providi ng a written statement of revocation to the  adjudi cator  at any time.  If revoke d, the rights to a ppeal re vert to the  beneficiary.  The transfer may be revoked in the  following  ways:  1. In writing by the beneficiary.  The  revocation must be  delivered to the  adjudi cator  and the pr ovide r or suppli er and is eff ective on the  date of receipt b y the adjudi cator.  2. By abandonment if the assignee does not f ile an appeal of  an unfavorable decision to the  financial interests of the beneficiary.  270.2.4 - When to Submit the Transfer of Appeal Rights  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  A provider or supplier may submit the completed transfer of appeal rights form to the MAC at the time he or she submits an appeal request.  The provider or supplier may obtain the completed transfer of appeal rights form from the beneficiary at the time th at the services are provided, and file the previously signed form with the appeal.   270.2.5 - Where to Submit the Transfer of Appeal Rights  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  When the provider or supplier submits the original or a copy of the signed transfer of appeal rights form, the MAC shall place it in the case file.  The provider or supplier should also give the beneficiary a copy of the completed form.   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 a copy of the signed transfer of appeal rights form when submitting an appeal.   270.2.6 - Rights of the Assignee of Appeal Rights  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  When a valid tra nsfer of appeal r ights is e xecuted, the beneficiary transfers all appeal r ights involving the item or service at issue  to the  provider or suppli er.  The transfer of appeal r ights b y a beneficiary must be  made freely and without c oercion.  T he MAC  shall assume  that a provide r or suppli er is not m aking false or misleading  statements, re presentations or  claims about a ny material fact a ffecting any persons rights.  How ever, if the MAC  has reason to be lieve that the assignee is m aking false or misle ading statements, re presentations or  claims about a ny material fact affecting any persons rights, it sh all refe r the m atter to the  UPIC .  A p rovider or suppli er accepting the transfer of appeal rights will h ave access to p ersonal and confidential medical and othe r information a bout a  beneficiary.  The MAC sh all assume  that the provider or suppli er will not dis close personal or confidential information a bout a  beneficiary except a s necessa ry to pur sue an appeal on be half of the party represented.  Further, it sh all assume  that a provide r or suppli er is not dis closing any personal or confidential medical or  other information a bout a  beneficiary outside  of the appeals process.  A beneficiary transfers all appeal r ights involving the  item or service at issue  to the  provide r or suppli er, these include, but are not limite d to:  1. Obt aining information about the  claim to the  same extent as the beneficiary; 2. Submitting  evidence; 3. M aking statements about facts or  law; and 4. M aking any request, or  giving , or receivi ng any notice about a ppeal proceedings.  When a MAC  takes action or  issues a redetermination, it sh all send no tice to onl y the a ssignee.  Notice shall not be  sent to the  beneficiary if there is an assignee.  The MAC  shall send any requests for information or  evidence regarding an appeal only to the  assignee.  270.2.7 - Duration of Transfer of Appeal Rights  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  Unless revoked the transfer of appeal rights is valid for all levels of appeal including judicial review.  This transfer remains in effect even in the event of the death of the beneficiary.   270.2.8 - Curing a Defective Transfer of Appeal Rights  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If any one of the elements is missing from the CMS -20031, the MAC shall contact the party and provide a description of the missing documentation or information.  If the defect is not cured, the prospective assignee of appeal rights lacks the authority to a ct on behalf of the party, and is not entitled to obtain or receive any information related to the appeal, including the appeal decision.   The MAC shall provide help and assistance to the beneficiary and provider or supplier in securing the transfer of appeal rights, based on the time frames set forth below.   A. Timely Filed Appeal Request with a Defective Transfer of Appeal Rights   When an inc ompl ete or defective  transfer of appeal rights form is received , the MAC shall notify both the provider/supplier submitting the CMS -20031 and the beneficiary.  The MAC shall advise them why the transfer is defective, and describe the missing information that is required to complete the transfer.  This may be done by t elephone or written notification.  The method, time and date of any notification shall be documented in the case file.  A corrected/completed transfer may be submitted to the MAC by mail, or at the MACs discretion, by facsimile or a secure Internet portal/application, within 14 days.  Should the CMS -20031 not be corrected within this time limit, the MAC proceeds with processing and rendering a decision on the appeal.  It sends the appeal decision to the beneficiary and any other party to the appeal, but not to the unauthorized assignee.  This will ensure that the beneficiary receives an appeal, as the presumption here is that the appeal originated with the beneficiary and was submitte d with the beneficiarys knowledge and consent.  However, if the MAC has information or evidence that the transfer was not submitted at the request of the beneficiary, it shall not conduct the appeal unless and/or until it receives confirmation from the be neficiary that the request was submitted with the beneficiarys approval.   B. Untimely Appeal Request Submitted With an Incomplete or Defective Transfer   Because an untimely -filed appeal request is not always dismissed (e.g., there could be the finding of good cause for late filing, see 240.1), an incomplete or defective CMS -20031 may, in some cases, need to be corrected.  If an incomplete or defective CMS -20031 needs to be corrected, the MAC shall follow the instructions contained in Section A above, prior to proceeding with the appeal request.  C. Untimely Appeal Request Submitted With a Valid Transfer   These cases should be resolved solely on the basis of whether there is good cause.  (See 240.1.)   270.2.9 - Disclosure of Individually Identifiable Beneficiary Information to Assignees  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  In accordance with the  provisions of  the Privacy Act, bef ore the MAC  may release beneficiary-specific information to a n assignee, the beneficiary must c ompl ete and sign a CMS-20031 na ming  that individua l as his/h er assignee.  The MAC  shall use  caution in re leasing beneficiary-specific information to a ssignees.  The assignee is entitle d to r eceive  only information th at an appoint ed representative  wou ld be entitled to receive (e.g., the  determination l etter) and tha t which is per tinent to the  case/claim for which appe al rights  have been assigne d.  A beneficiary must e xplicitly author ize the release of any information th at is not speci fic to the cas e/claim for which appeal rights ha ve been ass igned.  A ny questions a s to wh ether information needs a uthorization to be released to a n assignee can be directed to the  appropriate CMS regional offi ce (RO).  For more information a bout the  disclosur e of identifiable information a bout b eneficiaries, see the M edicare General Information, Eli gibilit y, and Ent itlement M anual, Pub. 100- 01, C hapter 6.  270.3 - Medicare Secondary Payer (MSP) Specific Limitations or Additional Requirements with Respect to the Appointment of Representatives                                  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The following instructions/rules apply with respect to MSP recovery claims , not withstanding any language to the contrary in other subsections of Section 270 Appointment of Representative.   For a MSP recovery claim involving a beneficiary debtor, the representative relationship typically arises in the context of the beneficiarys claim against a workers compensation plan, liability insurance (including self-insurance), or no- fault insurance.   The representative is not hired solely to represent the beneficiary with respect to the recovery demand letter/debt at issue on appeal; the representative is routinely hired in connection with an underlying liability, no- fault or workers' compensation cl aim.  For MSP recovery claims involving a debtor other than a beneficiary or a provider/supplier, follow the instructions in the MSP IOM, Pub. 100- 05, Chapter 7, section 10, regarding authorization to represent a debtor.  For MSP recovery claims involving a provider/supplier debtor, follow the instructions for non- MSP.   The instructions below contain exceptions or additions to the non- MSP rules for MSP recovery claims involving a beneficiary debtor .  A. Appointment of Representative   For MSP recovery claims involving a beneficiary debtor, the representative relationship may be established in the following ways (the document must always include the beneficiarys Medicare number as well as his/her name):   1. If the representative is an attorney, by:    A copy of the fee agreement between the beneficiary and the attorney, signed by the beneficiary and signed/countersigned by the attorney,    A statement on the attorneys letterhead accompanied by a release signed by the beneficiary, or    A document compliant with the non- MSP rules.   2. If the representative is a non -attorney, follow the non- MSP rules.  However, note that information may be released to a non -representative regardless of whether or not there is a proper appointment of representative if the individual or entity has a proper  HIPAA compliant release from the beneficiary.   B. Duration of Appointment   The duration of the appointment lasts until revoked by the beneficiary absent specific language in the appointment document limiting the duration of appointment.  This is true regardless of whether or not an appeal has been filed within 1 year of the date of the appointment.  C. Correspondence  Both the beneficiary and the representative shall receive copies of all correspondence (including all appeals determinations).   D. Death of a Beneficiary   The death of the beneficiary terminates the authority of any representative appointed by the beneficiary.  The representative must obtain a new appointment from the beneficiarys estate or the individual assuming responsibility for the estate if there is no formally appointed executor.   280 - Fraud and Abuse  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  280.1 - Fraud and Abuse - Authority  (Rev. 2926, Issued: 04- 11-14, Effective: 07 -14-14, Implementation: 07- 14-14)  To protect the Medicare program from fraud and abuse, civil and criminal violation provisions have been included in 1107, 1128A , 1128B , 1872, and 1877 of the Act.