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Use Your Plan: Appointed Representatives

Medicare beneficiaries may have an appointed representative act on their behalf in the Medicare appeal process. An enrollee may appoint a willing relative, friend, health care provider, lawyer, or anyone else of their choice. Medicare beneficiaries who cannot make their own medical decisions may have a court-appointed guardian or conservator act on their behalf, according to state laws. The appointed representative may do anything that a Medicare beneficiary can do in the Medicare appeal process, including filing a request, submitting evidence, and receiving notices from the Medicare drug plan.

You may have a different appointed representative for each medicine. So, for example, if you are requesting coverage of both a heart medication and a medication for depression, then your cardiologist may be your appointed representative for your heart medication and your psychiatrist may be your appointed representative for your anti-depressant medication. It is important to remember that your health care provider is not automatically your appointed representative. If you want your health care provider to help with the Medicare appeal process, you must file a form to designate him or her, just as if you were designating a friend of relative.

In order for the appointed representative to be recognized by the Medicare drug plan, you need to file an Appointment of Representation Form (federal form # CMS-1696 or a similar form that the plan may design) with the plan, or submit a letter that includes:

  • the enrollee's name, address, and phone number
  • the enrollee's health insurance claim number for the specific denied drug
  • the appointed representative's name, address, and phone number
  • a statement that the enrollee is authorizing the appointed representative to act on his or her behalf and to receive personal medical information about the enrollee
  • the enrollee's signature and date signed
  • a statement that the appointed representative accepts the appointment
  • the appointed representative's signature and date signed

It is probably easiest to call the plan's member services department and ask them to send you a form. (The telephone number for member services is usually on the back of your pharmacy benefit ID card.) Enrollees who have a court or state appointed guardian do not need to file an Appointment of Representation form. Instead, they can file a copy of the same form that was used to appoint them as a legal guardian.

An Appointment of Representation form or legal appointment documentation should be submitted with each new request for coverage. If the Appointment of Representation form that you used for a prior request for coverage was signed within the past year, you can use a copy of that form with the new request for coverage. If not, you must complete and sign a new form. It is probably safest to enclose a copy of the Appointment of Representation form with every step of the Medicare appeal process, just in case the plan has not kept a copy in your case file. A plan is not required to review an request for coverage submitted by an Appointed Representative if it does not have documentation of a valid appointment of the representative.