Asking for Organization/Coverage Decisions
An organization/coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services or drugs. We and/or your doctor make an organization/coverage decision for you whenever you go to a doctor for medical care. You can also contact the Plan and ask for an organization/coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make an organization/coverage decision for you.
We are making an organization/coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Organization/Coverage Decisions – Instructions
Click on your plan number under "Complete EOC" to view the full version or click on the plan number under "Organization/Coverage Determination" to find instructions on organization/coverage decisions.
Appointment of a Representative
The Appointment of Representative Form (PDF, 66 KB) is located on the CMS Web site.
Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form, must be submitted with the appeal and is valid for one year from the date. The form must be signed by both you and the appointed representative. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.
The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
- Members of beneficiary advocacy groups
- Members of provider or supplier advocacy groups
- Physicians or suppliers
- Congressional staff members
- Family members of a beneficiary
- Friends or neighbors of a beneficiary
The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 29, section 270.1) for required elements of written instruments. You may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.
The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative. Instructions for completing the form:
- The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
- Completing Section I - 'Appointment of Representative' - A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
- Completing Section II - 'Acceptance of Appointment' - The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
- Completing Section III - 'Waiver of Fee for Representation' - This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal
- Completing Section IV - 'Waiver of Payment for Items or Services at Issue' - This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Social Security Act
If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision.
Where to Send This Form
Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.
You can also call the Member Services Department to learn more about how to name your appointed representative.
The plan requires prior authorization (approval in advance) of certain covered drugs that have been approved by the FDA for specific medical conditions. Contact Us for more information.