Medicare appeal some common question - Part 1

Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?

A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.

Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.
The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:

• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Q: During the appeal process, at what point can additional records be submitted?

A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records they received to the affiliated contractor, or First Coast Service Options Inc.

Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?
A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.


Q: What does the term “amount in controversy” mean?
A: The amount in controversy (AIC) is the amount in dispute, at a minimum, that you must have for the administrative law judge (ALJ) and judicial review levels in the appeal process.

: Is there a resource for providers or beneficiaries that outline what services or items can be appealed?
A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.