December 20, 2021 - Revised April 19, 2022
Billing Agency Appointment of Representative for Appeals — Revised
This article was revised on 4/19/22 to clarify the appointment of representative statement may be in an electronic format.
A redetermination request must be submitted by someone who is considered a party to the appeal. The appeal will be dismissed if the person requesting is not a proper party.
Important Reminder: Suppliers who retain a billing agency to handle their appeals need to submit a properly executed appointment of representative. Suppliers can use the Form CMS-1696 Appointment of Representative
or submit a statement containing all of the required elements.
See the excerpt below from Chapter 13 of the Supplier Manual
for information about parties to an appeal and appointment of representative:
Parties to an Appeal
An appeal request must be submitted by someone who is considered a party to the appeal. The appeal will be dismissed if the person requesting is not a proper party. Any of the following are considered proper parties to an appeal:
- A beneficiary;
- A participating supplier;
- A non-participating supplier taking assignment for a specific item or service;
- A non-participating supplier of DME potentially responsible for making a refund to the beneficiary under Section 1834(a)(18) of the Act;
- A supplier of medical equipment and supplies not taking assignment and who is responsible for making a refund to the beneficiary under Section 1834(j)(4) of the Act;
- A Medicaid State agency or party authorized to act on behalf of the State; or
- Any individual whose rights may be affected by the claim being reviewed
Appointment of Representative
To act as the beneficiary’s representative, a person/supplier/physician must submit a properly executed appointment of representative form – Form CMS-1696,; however, the appointment of representative form is not necessary. A written statement containing all the required elements is also acceptable as a valid appointment of representative. A valid appointment of representative statement must:
- Be in writing, signed (handwritten or electronic, digital, and/or digitized), and dated by both the party and the individual agreeing to be the representative;
- Provide a statement appointing the representative to act on behalf of the party, and authorizing the adjudicator to release identifiable health information to the appointed representative;
- Include a written explanation of the purpose and scope of the representation;
- Contain both the party’s and appointed representative’s name, phone number, and address
- Contain a unique identifier of the party being represented. If the party being represented is the beneficiary, the Medicare number must be provided. If the party being represented is a provider or supplier, the National Provider Identifier number should be provided;
- Include the appointed representative’s professional status or relationship to the party; and
- Be filed with the entity processing the party’s initial determination or appeal (i.e., the DME MAC).
The appointment of representative is valid for one 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.
The appointment remains valid for any subsequent levels of appeal on the claim/service in question unless the beneficiary specifically withdraws the representative's authority. However, if during an appeal the appointment of representative expires, a new form is necessary.
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