Crosswalk Document Cms1696_031808

CROSSWALK DOCUMENT FOR CHANGES TO CMS-1696

(APPOINTMENT OF REPRESENTATIVE FORM)

SUBMITTED FOR COLLECTION JANUARY 2008

SUMMARY OF CHANGES TO CMS-1696: The form “Appointment of Representative” is primarily used by Medicare beneficiaries in conjunction with filing appeals on Medicare claim denials. After the form was issued in 2005, CMS received several requests to alter the form so that it can be used by both Medicare beneficiaries and Medicare providers who seek to appoint a representative to assist them in their pursuit of a Medicare claim appeal. We have changed areas of the form that previously referred specifically to “beneficiary” so that those areas now serve a general audience.

FIRST SECTION:

• Changed the 1^st fill in area from “Name of Beneficiary” to “Name of Party.”

• Changed the 2^nd fill in area from “Medicare Number” to “Medicare or National Provider Identifier Number.”

• Under “Section I”: First line of instruction changed from: “To be completed by the beneficiary” to “To be completed by the party seeking representation (i.e. the Medicare beneficiary, the provider or the supplier)”.

• Under “Section I”: Changed the 1st fill in area from “Signature of Beneficiary” to “Signature of Party Seeking Representation”.

• Under “Section I”: Changed 4^th fill in area from: “Phone Number (Area Code) to “Phone Number (With Area Code).

• Under “Section II”: In the text area, changed: “...disqualified from acting as the beneficiary’s representative; and...” to “disqualified from acting as the party’s representative; and...”

• Under “Section II”: Changed the 1^st fill in area from, “Signature” to “Signature of Representative”.

• Under “Section II”: Changed 4^th fill in area from: “Phone Number (Area Code) to “Phone Number (With Area Code).

• Under “Section III”: In the text area, changed: “Instructions: This form should be filled out if the representative waives a fee for such representation. (Note that providers or suppliers may not charge a fee for representation and thus, all providers or suppliers that furnished the items or services at issue must complete this section.) to “Instructions: This section must be completed if the representative is required to or chooses to waive their fee for representation. (Note that providers or suppliers that are representing a beneficiary may not charge a fee for representation and thus, must complete this section.).

• Under “Section IV”: In the text area, changed: “Instructions: Providers or suppliers that furnished the items or services at issue must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, and could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for furnished items or services at issue involving 1879(a)(2) of the Act.” to “Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, or could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.). I waive my right to collect payment from the beneficiary for furnished items or services in this appeal if a determination of liability under 1879(a)(2) of the Act is at issue.”

• Page 2 (or back of document), under “Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human Services: Changes to 1^st paragraph:

An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e. an Administrative Law Judge (ALJ) hearing, or Medicare Appeals Council (MAC) review, or a proceeding before an ALJ or the MAC as a result of a remand form a federal district court) is required to obtain approval of the fee in accordance with 42 CFR §405.910(f).

• Page 2 (or back of document), under “Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human Services: Changes to 2nd paragraph:

The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for MAC review.

• Page 2 (or back of document), under “Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human Services: Changes to 3rd paragraph:

Approval of a representative’s fee is not required if (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or a reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation.

• Page 2 (or back of document), after the section “Conflict of Interest”, add another section entitled: “Where to Send this Form” WHERE TO SEND THIS FORM

Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision.

If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1- 800-633-4227).

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