Appointment of Representative Instructions
Chapter 13, Medicare Managed Care Manual

60.1.2 - Authority of a Representative

(Rev. 22, 05-09-03)

A representative may:

• Obtain information about the enrollee's claim to the extent consistent with current Federal and state law;
• Submit evidence;
• Make statements of fact and law; and
• Make any request, or give or receive any notice about the appeal proceedings

60.1.1 - Representatives Filing Appeals for Enrollees

(Rev. 80, Issued: 03-03-06, Effective Date: 03-03-06)

Individuals who represent enrollees may either be appointed or authorized (for purposes of this chapter [and the definition under 42 CFR Part 422, Subpart M], they are both referred to as "representatives"). An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal on his or her behalf. Also a representative (surrogate) may be authorized by the court or act in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date and complete a representative form (for purposes of this section, "representative form" means a Form CMS-1696 Appointment of Representative or other conforming instrument). Due in part to the incapacitated or legally incompetent status of an enrollee, a surrogate is not required to product a representative form. Instead, he or dshe must product other appropriate legal papers supporting his or her status as the enrollee's authorized representative. Medicare health plans with service areas comprising more than one state should develop internal policies to ensure that they are aware of the different State representation requirements in their service areas.

Either the signed representative form for a representative appointed by an enrollee, or other appropriate legal papers supporting an authorized representative's status, must be included with each appeal. Regarding a representative appointed by an enrollee, unless revoked, an appointment is considered valid for one year from the date that the appointment is signed by both the member and the representative. Also, the representation is valid for the duration of the appeal. A photocopy of the signed representative form must be submitted with future appeals on behalf of the enrollee in order to continue representation. However, the photocopied form is only good for one year after the date of the enrollee's signature. Any appeal received with a photocopied representative form that is more than one year old is invalid to appoint that person as a representative and a new form must be executed by the enrollee.

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