Knowledge Base Article

Q:

What is required if a hospital wants to outsource its Medicare appeals?

A:

The hospital will need to follow the instructions in Section 270, Chapter 29, Medicare Claims Processing Manual.
Some key points from these instructions include:

• 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 released only to the individual so named.
• A written appointment of the representative must be submitted: the hospital can use Form CMS-1696 or a written instrument which must contain:
• A statement appointing the representative to act on behalf of the hospital, and authorizing the adjudicator to release identifiable health   information to the appointed representative;
• A written explanation of the purpose and scope of the representation;
• Dated, handwritten ink signatures of both the hospital signee and the individual accepting the appointment (both must sign the request within 30 days of each other);
• The name, phone number and address of both the hospital and the representative;
• The representative’s professional status and relationship to the appointing party; and
• The hospital’s NPI number.
• Appointed representatives are responsible for submitting a valid appointment instrument to the contractor with each new appeal request.
• A photocopy of the original may be submitted as long as the original is available upon request.
• Resubmission of the instrument at subsequent levels of appeal for the item(s)/service(s)/claims(s) at issue is encouraged though not required.
• The hospital may appoint a representative to assist with filing an appeal at any time during the course of an appeal.

“If an individual is attempting to act as a representative of a party that is not the beneficiary (such as a hospital) and fails to include an appointment instrument with the appeal request, the individual lacks the authority to act on behalf of the party, and is not entitled to obtain or receive any information related to the appeal. The MAC shall notify the   individual that no redetermination will be performed until a valid request is received from the party or a valid appointment instrument is resubmitted with the redetermination request.”