evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If the beneficiary is deceased, the  legal representative of the estate may file an app eal.  In the a bsence of a legal representative, any person who has assum ed responsibili ty for settling  the d ecedents estate may file the appeal.  In the se situations, the  MAC  shall obt ain proof that the person ha s assum ed responsibili ty for settling the  deced ents estate (e.g., a will or  probate court doc ument).  What is accept able as legal documentation m ay vary according to State law.  The  MAC  shall notif y the person f iling the appeal a bout the documentation neede d to s how the  person is e ither the legal representative of the estate or the person who has assum ed re sponsibili ty for settling the  dece dent's estate and describe the types of documentation neede d.  Allow a t least 14 cal endar days for the documentation to be  submitt ed.  If, at the end of  the time allowed, the  documentation neede d is not submitt ed, dismiss the  request.  If the appellant submits the  documentation af ter the allotte d tim e, the MAC c onsid ers good c ause for late filing.  In suc h inst ances, the MAC  documents the file to show the  basis for that persons filing the appeal.  MACs shall follow state law when determining proper parties to initial determinations and appeals. Legal representatives of deceased beneficiaries can be proper parties to initial determinations and appeals.  In order to verify that the requester is the pr oper representative, MACs shall be aware of the current state laws in their jurisdictions and shall accept any documentation acceptable by the appropriate state.  The documentation must be sufficient to verify that the individual making the request is a pr oper and valid representative for purposes of initial determinations and appeals under 42 CFR Part 405.  Examples of proper documentation based on state law include, but are not necessarily limited to:    Probate court documents (such as, letters of administration or letters of testamentary to an executor named in the deceased beneficiarys will).    The deceased beneficiarys will naming the executor.    Appointment of Representative document (CMS -1696 form or other similar document).
(Medicare Claims Processing Manual)
 The deceased beneficiarys will naming the executor.    Appointment of Representative document (CMS -1696 form or other similar document).    An instrument executed by a beneficiary that confers representative authority in accordance with state law (for example, health care proxy appointment, Power of Attorney form, or Durable Power of Attorney form).    Representative appointment made by a court of law on behalf of a deceased beneficiary that has not named an executor to handle his or her estate.    Examples of insufficient documentation include:   Claims against the decedents estate without an authorized representative listed.    Any unsigned writing conferring authority on the party to act as a legal representative.    The beneficiarys certificate of death.   270.1.8 - Disclosure of Individually Identifiable Beneficiary Information to an Appointed Representative (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 appoint ed representative, the beneficiary or appellant must c ompl ete and sign CMS-1696, or othe r conforming  written inst rument, na ming  that individua l as his/h er representative.  The MAC  shall use caution in re leasing beneficiary-specific information to appoint ed representatives.  The  representative is entitle d to r eceive  only information th at the party (beneficiary or appellant) would be  entitle d to r eceive  (e.g., the de termination l etter) and that whi ch is p ertinent to the  case/claim for which the representative is being a ppoint ed.  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, Chapter 6: see also 300 be low.  270.2 - Assignment of Appeal Rights  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07-23 -13)
(Medicare Claims Processing Manual)
270.2 - Assignment of Appeal Rights  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07-23 -13)  270.2.1 - Assignment of Appeal Rights - Introduction  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  A beneficiary may assign his or her appeal rights to a provider or supplier who furnished an item or service to the beneficiary that is at issue in an appeal.  Only providers or suppliers who are not a party to the initial determination may accept assignme nt of appeal rights from a beneficiary (See 210 for information on who is a party to an appeal.)   Because beneficiaries have difficulty understanding the term assignment of appeal rights, we use the term transfer of appeal rights on the related form and for communication to beneficiaries.  For the remainder of these instructions, we will also use t he term transfer instead of assignment of appeal rights, whenever appropriate.  The transfer of appeal rights is valid for the duration of the appeal, unless revoked by the beneficiary.   270.2.2 - Who May Be an Assignee  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  Only a provider or supplier that is not a party to the initial determination and furnished an item or service to the beneficiary may accept the transfer of a beneficiarys appeal rights for that item or service.   An individual or entity who is not a provider or supplier may not accept the transfer.  A provider or supplier that furnishes an item or service to a beneficiary may not accept the transfer for that item or service when considered a party to the initial de termination.   270.2.3 - How to Make and Revoke a Transfer of Appeal Rights  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
270.2.3 - How to Make and Revoke a Transfer of Appeal Rights  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The beneficiary making the transfer (assignor) and the provide r or suppli er accepting the transfer (assignee) must c ompl ete the CMS standardized Transfer of Appeal R ights form (F orm CMS-20031) .  This f orm is entitle d, Transfer of Appeal Rights.  No al ternative written instrument may be used.  Signatures may be handwritten, electronic, digital, and/or digitized.  B y signing the CMS-20031, the  provide r indi cates his/h er acceptance of being the assignee.  Page two o f the form provide s information to the  beneficiary about transferring appeal rights.  The form C MS-20031 is a vailable  on the C MS.gov website at:  http://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/Downloads/CMS20031.pdf   A. Co mpleting a valid  Transfer of Appeal Rig hts Form CMS-20031  Form CMS-20031, T ransfer of Appeal R ights, is the  required form that beneficiaries must use  to assign the ir appeal  rights.  F ollowing ar e instructions for compl eting f orm CMS-20031.  1. Completing Section I - The name of the beneficiary transferring appeal r ights must be  clearly legible.  The be neficiarys Me dicare numbe r must be  provide d in this s ection.  This s ection in cludes name, Medicare number , address and ph one numb er, and the  item or service that is a t issu e.  The  beneficiary must provide a signature on the  transfer statement and inc lude the date.  Only the beneficiary may sign this s ection.
(Medicare Claims Processing Manual)
2.   C ompleting Section II - Acceptance of Appeal Rights - The provide r or suppli er acc epting the appeal  rights must c ompl ete this s ection.  This s ection in cludes name, address, and phone  num ber.  The provide r or suppli er must si gn this s ection to accept the t ransfer of appeal rights and agree not to collect payment (except f or any applicable d eductible or coinsur ance) from the  beneficiary for the item or service at issue, unless a v alid Adva nce Beneficiary Notice of N oncoverage (ABN) is in effect.  If an inc ompl ete form is submitte d, the  adjudi cator  should c ontact the  party and pr ovide  a description of  the missing  information.  Unl ess the  defect is c ured, the provider or suppli er lacks the  author ity to accept the  appeal r ights of  the beneficiary, and is not e ntitle d to t ake action r egarding the appeal or obtain or receive any information re lated to the  appeal, in cluding the appeal d ecision.  The  adjudicator  should not dismiss the  appeal reque st because  the transfer of appeal  rights is not  valid.  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 MAC of his or her inability to sign their signature due to their disability.  By affixing the rubber stamp, the person is cer tifying that they have reviewed the document.  B. Waive r of Right to Payment for the Items or Services a t Issu e
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B. Waive r of Right to Payment for the Items or Services a t Issu e  The provide r or suppli er who acc epts the  appeal rights must w aive the right to collect p ayment from the  beneficiary for the item or service that is the  subj ect of the appeal.  The provider or suppli er may collect any applicable  deductible or coinsura nce.  The  provider or suppli er agrees to this w aiver by compl eting and signing Section  II of the Transfer of App eal Rights form.  The w aiver to collect payment remains in effect regardless of the outcome of the appeal decision.   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)
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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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.   280.2 - Inclusion and Consideration of Evidence of Fraud and/or Abuse  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The MAC sh all inq uire fully into the  matters at issue  by receiving, in e vidence, the t estimo ny of witnesses and any documents th at are relevant to the  claims a t issu e.  If the MAC  believes that evidence has been t ampered with, it sh all refe r this documentation to e ither the medical review or the UPIC s units f or their follow -up.