Appeals Filed by a Representative

Enrollees & Representatives

Appeals Filed by a Representative

An enrollee may appoint anyone to act as his or her representative to request an appeal. When the enrollee properly appoints another individual to act on his or her behalf, the appointed individual has all of the same rights as the enrollee with respect to the appeals process.

Enrollee Appointed Representatives
An authorized representative is an individual who has been appointed by the enrollee or who is authorized by state or other applicable law to act on behalf of the enrollee in requesting an appeal.

An enrollee can authorize another to act on his or her behalf by filling out an Appointment of Representative Form (AOR) or other written document containing the same information. The AOR is the preferred method, as the CMS form contains all of the required fields. The enrollee may appoint anyone to act on his or her behalf, including a spouse, child, relative, friend, advocate, attorney, physician or an employee of a pharmacy or charity. Note that attorneys are also required to provide representation documents. Proof that the attorney was retained by the enrollee is not sufficient proof of representation.

Appointment of Representative Form (CMS-1696)

How to Appoint a Representative
In order to appoint a representative, the enrollee must complete a writing that sets forth the following information:

  1. Identifies the name, address, Medicare claim number (HIC#) and phone number of the enrollee
  2. Identifies the name, address and phone number of the individual being appointed
  3. Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue
  4. Contains a statement authorizing disclosure of individually identifying information to the representative
  5. Contains the enrollee’s signature and the date signed
  6. Contains the representative’s signature and the date signed, and is accompanied by a statement indicating that the representative accepts the appointment.

If any of the above elements are missing or incomplete, the form or writing is not valid and would need to be returned for proper completion. This would result in a delay in processing the appeal

Appointment under State law
A representative may also appeal on behalf of an enrollee pursuant to state laws allowing the appointment of legal representatives. State laws allow an enrollee to appoint a representative by completing a Power of Attorney (POA) or healthcare proxy. This type of appointment may be effective immediately, while others may only become effective after the enrollee has been found legally incompetent. It is crucial that the enrollee understand the legal effect of whatever instrument or means is used to appoint a representative. A representative may also be authorized to act on an enrollee’s behalf by a court of law. For example, a court of law may appoint an individual or entity to act on behalf of an incompetent enrollee (e.g. guardianship proceeding).

Therefore, when filing an appeal with the Part D Qualified Independent Contractor (QIC), a non-enrollee appellant may appeal on an enrollee’s behalf only if he or she has the legal authority to do so. The non-enrollee appellant is required to prove validity of representation by submitting a copy of the legal document that confers representative authority with the appeal request. The Part D QIC may dismiss cases that lack valid appointment of representative documentation.

Appointment due to Incapacitated or Incompetent Enrollees
An enrollee who becomes incompetent or incapacitated, and does not have an authorized representative to act on his or her behalf, does not lose the right to request an appeal. Many states have surrogacy laws that identify those individuals permitted to act as a surrogate for healthcare decision-making purposes on behalf of an incapacitated or incompetent enrollee. A surrogate asserting that he or she is acting under a state's surrogacy requirements must include a statement verifying his or her status under state law in the same manner that an appointed representative must submit a valid Appointment of Representative (AOR) form or other equivalent written document. If a surrogate submitted the appropriate statement or documentation showing representative authority to the Part D plan, he or she cannot be required to submit an additional AOR form or other equivalent written notice when appealing to the Part D QIC.