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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


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Appointing a Representative

A party may appoint any individual, including an attorney, to act as his/her representative in dealings with the MAC. Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.

The appointment of a representative is valid for one year from the date signed by both the party and the appointed representative.

Who May Be an Appointed or Authorized Representative

Any individual may be appointed to act as a representative unless he/she is disqualified, suspended, or otherwise prohibited by law from acting as a representative in proceedings before the Department of Health and Human Services (DHHS), or in entitlement appeals, before SSA.

A provider or supplier who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative of the beneficiary. To act as the beneficiary’s representative, the provider or supplier must execute a valid appointment.

Billing clerks or billing services employed by the provider or supplier to prepare and/or bill the initial claim, process the payments, and/or pursue appeals act as the agent of the provider or supplier and do not need to be appointed as representative of the provider/supplier. Include evidence in the case file if the physician or other supplier employs a billing clerk or billing service (a screen print showing that payment is made to the billing clerk or billing service is sufficient.) If the billing clerk/billing service is not authorized to receive payment, but is authorized to process payments and/or pursue appeals, include evidence in the case file. If the agreement is on file, make a notation in the case file where the agreement can be located.

The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive, and is meant for illustrative purposes only:

    • Congressional staff members;
    • Family members of a beneficiary;
    • Friends or neighbors of a beneficiary;
    • Member of a beneficiary advocacy group;
    • Member of a provider or supplier advocacy group;
    • Attorneys; and
    • Physicians or suppliers.

How to Make an Appointment

The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument (see subsection B below, for required elements of written instruments). A party may appoint a representative to assist with filing a claim, or at any time during the course of an appeal. In order to constitute a valid appointment, the CMS-1696 or other conforming written instrument must contain a handwritten ink signature of the representative and the party, and each individual must sign the written instrument within 30 days of the other. (See subsection A, below, for exceptions.) By signing the appointment, the representative indicates his/her acceptance of being appointed as representative. The form CMS-1696 can be found at:

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.html

A handwritten ink signature means the scripted name or legal mark of an individual, handwritten by that individual and executed or adopted with the present intention to authenticate a writing in a permanent form.

Completing a Valid Appointment of Representative (Form CMS-1696)

The CMS-1696 is available for the convenience of the beneficiary or any other party to use when appointing a representative. 

Following are instructions for completing the form:

  • The name of the party making the appointment must be clearly legible. If the party being represented is the beneficiary, the Medicare number (also known as a Health Insurance Claim Number or HICN) must be provided. If the party being represented is a provider or supplier, the National Provider Identifier number should be provided. If the party being represented is an applicable plan in an appeal the space may be left blank. A HICN is required only when the beneficiary is the party appointing a representative.
  • Completing Section I – “Appointment of Representative”- The party making the appointment includes their handwritten ink signature, address, and phone number. If the party that wishes to appoint a representative is a beneficiary, then only the beneficiary or the beneficiary’s legal guardian may sign. If the party making the appointment is the provider or supplier, the provider or supplier (or person authorized to act on behalf of the provider or supplier) must sign the form and complete this section. The date the party signs the form must be included.
  • Completing Section II – “Acceptance of Appointment”- A specific individual must be named to act as representative in the first line of this section; a party may not appoint an organization or group to act as representative. The name of the individual appointed as representative must always be completed, and his/her relationship to the party entered. The individual being appointed signs the form with a handwritten ink signature, dates and completes the rest of this section.
  • Completing Section III – “Waiver of Fee for Representation”- This section must be completed when the beneficiary is appointing a provider or supplier as representative, and the provider or supplier being appointed has furnished the items or services that are the subject of the appeal.
  • Completing Section IV – “Waiver of Payment for Items or Services at Issue” – This section must be completed when the beneficiary is appointing a provider or supplier who furnished the items or services that are the subject of the appeal and the appeal involves issues described in §1879(a)(2) of the Act (limitation on liability).

If any of the required elements listed above are missing from the appointment, or are determined to be invalid (e.g. the signature does not meet the requirements of this section), the appointment is considered defective.

Prohibition Against Charging a Fee for Representation

A provider or supplier that furnished items or services to a beneficiary may represent that beneficiary on the beneficiary’s claim or appeal involving those items or services. However, the provider or supplier may not charge the beneficiary a fee for representation in this situation. Further, the provider or supplier representative being appointed as representative must waive any fee for such representation. The provider or supplier representative does this by completing section III of the CMS-1696. Alternatively, the provider or supplier must include a statement to this effect on any other conforming written instrument being used and must sign and date the statement.

Waiver of Right to Payment for the Items or Services at Issue

For beneficiary appeals involving a liability determination under §1879 of the Act where the provider or supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the provider or supplier must waive, in writing, any right to payment from the beneficiary for the items or services at issue (including coinsurance and deductibles). The provider or supplier representative does this by completing section IV of the CMS-1696 or other conforming written instrument and must sign and date the statement.

The prohibition against charging a fee for representation, and the waiver of right to payment from the beneficiary for the items or services at issue, do not apply in those situations in which the provider or supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e., where the provider or supplier is not also acting as representative for the beneficiary), or where the items or services at issue were not provided by the provider or supplier when the provider or supplier has been appointed as the beneficiary’s representative.

When and Where to Submit the Appointment

A representative, beneficiary, or other party may submit the completed appointment to the contractor at the time such person files a claim or request for appeal or at any time during the processing 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 containing handwritten ink signatures, or a photocopy of the original. A photocopy of the original is acceptable, provided the original contains handwritten ink signatures of the party and the representative and is otherwise valid. Should a photocopy of the original appointment instrument be submitted with an appeal request, the original appointment instrument must be maintained by the representative or the party, and produced upon request.  If an appeal or other motion is filed by a representative on behalf of a party to the appeal, but does not include an appointment, the contractor takes the actions to secure the written appointment.

If a valid CMS-1696, or other conforming written instrument, has previously been filed with the contractor, the representative is encouraged, but not required, to submit a copy at subsequent levels of appeal. 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. However, if a new appeal for different items/services/claims is initiated during the one year timeframe of the appointment, a copy of the appointment must be filed with the new appeal request.

Duration of Appointment

An appointment is considered valid for one (1) year from the date that the CMS-1696 or other conforming written instrument contains the signatures of both the party and appointed representative. Requiring that a new appointment be executed on a yearly basis will help ensure that there is an ongoing relationship between the party and his/her representative.

Appeals for other claims may be initiated utilizing an existing appointment instrument within one year of the effective date of the appointment (i.e. the date a completed appointment instrument is signed by the party and the appointed representative). When initiating a new appeal within the one year timeframe, the representative must file a copy of the completed appointment instrument with the appeal request. Allowing the representative to use the same appointment for up to one year will help reduce the paperwork involved in representing parties. The MAC may also place information about appointment validity in provider newsletters, bulletins, educational materials, etc.

The appointment remains valid throughout any and all subsequent levels of administrative appeal on the claim or claims at issue. Therefore, the representative need not secure a new appointment when proceeding to the next level of appeal on the same items, services or claim(s). This holds true regardless of the length of time it may take to resolve the appeal.



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