evekhm/cms_iom_500 huggingface dataset:
(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.
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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;
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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)
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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.
(Medicare Claims Processing Manual)
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
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 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;
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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 .  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.
(Medicare Claims Processing Manual)
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
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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.
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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.
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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
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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
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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
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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)  If at any time after the execution of  a valid appoint ment or nondur able power of attorney the b eneficiary becomes incapacita ted and is una ble to m anage his/h er affairs, the  appointm ent becom es inva lid.  The  MAC  shall resolve  who has legal author ity to act on be half of the beneficiary before disclosing any further information pur suant to the  appointm ent or nondu rable pow er of attorney.
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If the beneficiary has executed a durable pow er of attorney that author izes the designated person to c onduc t the beneficiarys affairs, or to m ake financial decisions on be half of the beneficiary, the representation doe s not become  inva lid upon the  beneficiarys sub sequent incapacitation.  NOTE:  Some dura ble pow ers of attorney do not  become  effective until a nd unl ess su ch an incapacit ation occurs.  The death of  a party terminates the author ity of the appoint ed representative.  How ever, if an appeal is in progress and anothe r individua l or entity may be entitle d to re ceive  or obligated to m ake payment for the items or  services th at are the subj ect of  the appeal, t he appointm ent remains in effect for the dura tion of  the appeal.  S ee also, 270.3 f or MSP specific limita tions or a dditiona l requirements.