Who May Be a Representative?

A party may appoint any individual, including an attorney, to act as his/her representative in dealing with a Fiscal Intermediary (FI). An organization may not be named as a representative; rather an individual from an organization may be a representative. A representative may be appointed at any point in the appeals process. Here is a list of types of individuals that may be appointed:

• Congressional staff member
• Family member
• Friend or neighbor
• Member of a beneficiary advocacy group
• Member of a provider or supplier advocacy group
• Attorney
• Physician or supplier

How Do I Make an Appointment?

Complete an Appointment of Representative form, SSA-1696 or submit a written statement that contains all the required elements. The following is a list of all the required elements:

• Name, address, and telephone number of the party seeking a representative
• Health Insurance Claim (HIC) number when the party making the appointment is the beneficiary
• Provider number when the party making the appointment is a provider
• Name, address, and telephone number of the party being appointed as a representative
• A statement that the party authorizing the representative to act on their behalf for the claim at issue
• A statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider)
• Signature of party making the appointment and the date signed
• Signature of individual accepting the appointment, accompanied by a statement that the individual accepts the appointment, and date signed

A representative must sign the appointment within 30 days of the party’s signature. With one exception, an attorney does not need an acceptance signature.

How Long Is an Appointment Good for?

An Appointment of Representative form is good for one year from:

1. either the date signed by the party making the appointment, or
2. the date the appointment is accepted by the representative, whichever is later.

The appointment remains valid for any subsequent levels of appeal. A copy of the appointment should be attached when submitting the next level of appeal. Unless the beneficiary withdraws the representative’s authority or the beneficiary becomes incapacitated.

The party appointing a representative may revoke the appointment by providing a written statement of revocation to the FI at any time.

When Is an Appointment Not Necessary?

If the requestor is the beneficiary’s legal guardian, surrogate decision maker for an incapacitated beneficiary, or otherwise authorized under state law, no appointment is necessary.

Are the Requirements Different if an Attorney Is the Representative?

If the person representing the party is an attorney, the attorney is not required to sign the representative form or a written statement. However, the party appointing the attorney must still sign the completed Appointment of Representative form or a written form making the appointment. The FI must assume that the attorney accepted the appointment within the 30 days.

What Rights Does a Representative Have?

A representative has all the same rights as the person/party they are representing. The representative may submit arguments, evidence or other materials on behalf of the appellant. The representative may obtain information from the FI regarding the claim or appeal at issue. The representative and the party may participate at all levels of the appeal. Any notice, acknowledgement, or determination letter must be sent to both the party and the representative. The appellant is the addressee with the representative receiving a copy of the notice.

What Are the Responsibilities of the Representative?

The appointment of representative by a party must be made freely and without coercion. The FI should assume that a representative is not making false or misleading statements, representations or claims about any material fact affecting any person’s rights.

The representative will have access to confidential information. The FI must assume that the representative will not disclose personal information except as necessary to pursue the appeal. The representative should not disclose any personal or confidential medical information outside of the appeals process.

A provider or supplier may not charge the beneficiary a fee to represent him/her. A statement to this effect should be included in the right to represent form or the written form.

A representative should keep a completed appointment on file and submit a copy with each claim appealed.

What if the Appointment of Representation Form Is Incomplete or Defective and the Represented Party Is the Beneficiary?

Here are the three different scenarios:

1. If an individual is attempting to represent a beneficiary and has submitted an incomplete or defective form, the FI must advise the individual how to complete the appointment. The FI allows 14 calendar days for a corrected appointment to be submitted. If at the end of the 14 days, no completed form is submitted, the FI should complete the appeal and notify the beneficiary and any other party to the appeal, but not an unauthorized representative.
2. If the FI has evidence (a signed Medicare Summary Notice [MSN]) that the beneficiary knew of or approved of the submission of the request for a redetermination and the representative does not send a right to representation form, no action is necessary. The appeal will be entered as a beneficiary request, and the FI should complete the appeal and notify the beneficiary and any other party to the appeal but not an unauthorized representative.
3. If the FI has evidence that the appointment was not submitted at the request of the beneficiary, the FI will not conduct the appeal unless confirmation is received from the beneficiary that the request was submitted with his/her approval. In this case, an Appointment of Representative form will be requested with the acknowledgement.

What if the Appointment of Representation Form is Incomplete or Defective and the Represented Party Is the Provider?

The FI notifies both the person submitting the appointment and the provider that the appointment is incomplete. The FI allows 14 days for the corrected/completed appointment to be submitted. It can be submitted by mail or facsimile. If the form is not correct/complete after the 14 days, the appeal request is dismissed, and the provider and the person submitting the appointment are notified.

Is a Power of Attorney Acceptable as a Valid Appointment?

An FI treats a power of attorney as a valid appointment if all the required elements are present and the power of attorney authorizes the designated person to conduct the beneficiary’s affairs. It can be general or very specific but it must at least state the beneficiary’s affairs or the beneficiary’s financial matters.

A power of attorney is exempt from the one year validity rule.

A power of attorney may be durable (i.e., surviving after the incapacitation of the beneficiary) or non-durable (i.e., automatically revoked upon the incapacitation of the beneficiary).

What Happens to the Appointment if the Beneficiary Becomes Incapacitated or Dies?

If it is a durable power of attorney that authorizes that designated person to conduct the beneficiary’s affairs or make financial decisions, that representative does not become invalid. If it is a valid appointment or a non-durable appointment, it becomes invalid. The FI must resolve who has legal authority to act on the behalf of the beneficiary.

Who Can File the Appeal if the Beneficiary Is Deceased?

The FI must obtain proof of one of the following:

• legal representative of the estate
• any person who has assumed responsibility for settling the beneficiary’s estate (a will or probate court document)

Note: Acceptable legal documentation may vary according to each state. If this is not sent with the appeal request, the FI must request it. The FI allows 14 days to obtain this information. If the documentation is not received after 14 days, the FI must dismiss the appeal request. If the documentation comes in after the allotted time, the FI must consider good cause for late filing.

What Information Can Be Disclosed to the Representative?

The representative is entitled to receive only information that the party (beneficiary or appellant) would be entitled to receive (i.e., determination letter) and that which is pertinent to the case/claim to which the representative is being appointed. Any questions as to what information can be released to a representative should be directed to the party’s respective Centers for Medicare & Medicaid Regional Office.