First Level of Appeal, Redetermination
If you are dissatisfied with the denial of a claim or believe that it was not properly paid, you may request a redetermination. All requests for redetermination must be requested within 120 days of the original claim determination.

All requests for a redetermination must be made in writing. Both the CMS-1964 form and Medicare Claim Inquiry and Appeal Form are available for your use in submitting a request. All requests must contain the following information. Your request for redetermination will be returned to you if missing one or more of the following:

• Beneficiary name;
• Medicare health insurance claim (HIC) number;
• Date(s) of service;
• Which item(s) and/or service(s) are at issue; and
• The name and signature of the appellant.

NOTE: The signature must be on the request for redetermination. Signatures contained on medical records are not acceptable as a valid signature for redetermination requests.

Requests for redetermination of nonassigned claims must include a completed Appointment of Representative form (CMS-1696 U4) or a written statement from the beneficiary giving authorization for you to submit a request on his/her behalf. Please see the Appointment of Representative section of this article for further information.

You are responsible for sending the carrier documentation in support of the case. Documentation may include:

• Billing forms
• Clinical summaries
• Consultation reports
• Copies of communications between physician and/or patient, hospital, carrier, laboratory, etc.
• Documentation of severity or acute onset
• Medical history
• Nurse’s notes
• Plan of treatment
• Referrals
• Test results
• X-ray reports

Second Level of Appeal

If you are not satisfied with the redetermination decision, your next level of appeal is the reconsideration. The reconsideration will be performed by the Qualified Independent Contractor (QIC) for all redeterminations issued and mailed January 1, 2006 and after. All redeterminations issued and mailed before January 1, 2006 will have appeals rights with the Contractor Hearing Office.

Please refer to the Medicare Claims Processing Manual, Chapter 29, Sections 330-345 for information regarding further appeals.

Additional Information Regarding the Appeals Process

Parties to an Appeal
Any of the following persons or entities are considered a party to an appeal of a claim for items or services payable under Part B and, therefore, may appeal the initial claim determination and any subsequent appeal decisions:

• A beneficiary.
• A participating physician or supplier (one who has agreed to accept assignment on all claims).
• A nonparticipating physician or supplier who has accepted assignment for a specific service/claim.
• A nonparticipating physician not accepting assignment, but responsible for refunding the beneficiary under section 1842(1)(1) of the Social Security Act.
• A nonparticipating supplier of durable medical equipment responsible for refunding the beneficiary under section 1834(a)(18) of the Social Security Act.
• A supplier of medical equipment and supplies furnishing items to a beneficiary on a nonassigned basis and responsible for refunding the beneficiary under section 1834(j)(4) of the Social Security Act.
• A Medicaid State agency, or party authorized to act on behalf of the State.
• Any individual whose rights with respect to the particular claim being reviewed may be affected by such review and any other individual whose rights with respect to supplementary medical insurance benefits may be prejudiced by the decision.

Requests for an appeal submitted by someone other than those listed will be dismissed.

Appointment of Representative
A party may appoint any individual, including an attorney, to act as his/her representative. Although some parties may pursue a claim or an appeal on his/her own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during both the processing and appeal of a claim or claims. The appointment of a representative is valid for 1 year from either 1) the date signed by the party making the appointment, or 2) the date the appointment is accepted by the representative, whichever is later.

Who May Be a Representative—Any individual may be appointed to act as a representative unless he/she is disqualified or suspended from acting as a representative in proceedings before CMS or is otherwise prohibited by law.

A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is only released to the individual so named.

A physician or other 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 physician or other supplier must meet the criteria set forth in this section.

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

NOTE: Billing clerks or billing services employed by the physician or supplier to prepare and/or bill the initial claim, process the payments, and/or pursue appeals act as the agent of the physician or other supplier and do not need to be appointed as representative of the physician/supplier.

How to Make and Revoke an Appointment—The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (Form CMS-1696-U4) or submit a written statement. A party may appoint a representative at any time during the course of an appeal. The representative must sign the appointment form or written statement within 30 calendar days of the date the beneficiary or other party signs in order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.

Attorney Representatives—If the person representing the party is an attorney, the attorney is not required to sign the representative form or a written statement. However, if it is not evident that the individual representing the party is an attorney, a business card, letterhead, or written statement is required.

Required Elements—The following information must be included on an appointment of representative form or written statement:

• Name/Address/Phone Number of party (i.e., the beneficiary or physician or other supplier).
• Health Insurance Claim Number, when the party making the appointment is a beneficiary.
• Medicare Physician/Supplier Number, when the party making the appointment is a physician or other supplier.
• Name/Address/Phone Number of the individual being appointed as representative.
• A statement that the party (i.e., the beneficiary or the physician or other supplier) is authorizing the representative to act on her/his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider of services).
• Signature of the party making the appointment and the date signed.
• Signature of the individual being appointed as representative, accompanied by a statement that he/she accepts the appointment, and the date signed; however, if the individual being appointed as representative is an attorney, the attorney does not need to accept the appointment in writing.
• Prohibition Against Charging a Fee for Representation:

A physician or other supplier that furnished items or services to a beneficiary may represent that beneficiary on his/her claim or appeal involving those items or services. However, the physician or other supplier may not charge the beneficiary a fee for representation in this situation. Further, the physician or other supplier being appointed as representative must acknowledge that he/she will not charge the beneficiary a fee for such representation. The physician or other supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.

• Waiver of Right to Payment from the Beneficiary for the Items or Services at Issue:

For beneficiary appeals involving the denial of the claim on the basis of §1862(a)(1) or (a)(9), or §1879(g) of the Act, and where a limitation on liability determination made under §1879 of the Act determined that both the beneficiary and the physician or other supplier, knew or could reasonably have been expected to know, that the item or service would not be covered, and where the physician or other supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the physician or other supplier must waive, in writing, any right to payment from the beneficiary for the items or services at issue (including coinsurance and deductibles). The physician or other supplier representative does this by including a statement to this effect on the form or written statement, and then signs and dates it.

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 physician or other supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e., where the physician or other supplier is not also acting as representative for the beneficiary), or where the items or services at issue were not provided by the physician or supplier representative.

When to Submit the Appointment—A representative, beneficiary, or other party may submit the completed appointment at the time such person files a request for appeal or at any time during the processing of the appeal.

Note that a completed appointment of representative form or written statement, or a copy of such form or statement, must be submitted with each appeal request.

Validity of an Appointment Over Time—A new appointment of representative form or written statement does not need to be executed each time an appeal is filed by the same representative who is representing the same party. For the administrative convenience of both the party making the appointment and the representative, the representative may maintain a completed appointment on file and then submit a copy with each new appeal request.