Acting for someone else

To help someone with a denial, get their written permission and send it to the plan. A plan must let an authorized representative act for the person in a claim or an appeal. The form differs by plan, by Medicare and by Medicaid, so ask what each one needs.

What this means

An authorized representative is a person the patient names to act for them in a claim or appeal. It can be a family member, friend, advocate, lawyer or doctor. Naming one is different from simply helping: it tells the plan in writing that the patient has agreed that you act for them.

The rules differ by coverage:

• Job-based and individual plans. The federal claims rule says a plan must let an authorized representative act for the claimant. In an urgent case, a health care professional who knows the patient’s condition must be allowed to act as the representative.
• Original Medicare. A person may appoint a representative on Form CMS-1696, Appointment of Representative. The list includes a family member, friend, advocate, attorney or doctor.
• Medicare Advantage. The member, a representative, or the treating physician (after telling the member) can ask for a reconsideration. An expedited request can be made orally.
• Medicaid. The state must tell people in writing about their right to be represented at a fair hearing. In Medicaid managed care, a provider can file the plan appeal for the enrollee only with the enrollee’s written consent and if state law allows. Providers cannot ask for continued benefits on the enrollee’s behalf.
• Veterans. The patient advocate at each Department of Veterans Affairs facility is a staff member whose job is to help resolve concerns and to help file a clinical appeal.
• Records. The Health Insurance Portability and Accountability Act (HIPAA) gives a person the right to their own records within 30 days, with one extension of up to 30 more days. We could not confirm who counts as a personal representative for that purpose. Ask the provider or plan for its own authorization form.

What to do

1. Talk to the person first (your step). Ask what they want you to do. Ask for their member number and the denial notice, and write down the deadline.
2. Find out their coverage type. See how to find out your plan type or the coverage type finder. The form depends on it.
3. Ask the plan what it needs. Call the number on the card with the person beside you if possible. Ask: “What do you need so that I can speak to you and file an appeal for this member? Can you send the form?” Ask for it in writing.
4. Use the plan’s form if there is one. Medicare has Form CMS-1696. If a plan has no form, use the authorized representative designation letter while you wait. The authorized representative helper tells you which to ask for.
5. The person signs, not you. Have them sign and date it. If they cannot sign, ask the plan what it will accept.
6. Send it with the appeal, and to each provider (your step). Send a copy to the plan and to the doctor’s office, with a proof of delivery. The Patient Advocate Foundation lists completing an authorized representative form as a practical step.
7. Ask for records the right way. Use the medical records request with the form the provider requires.
8. Keep your own file. Log who you spoke to, the date and what was promised. Keep the original deadline in view. Check the date on the notice, which controls.

What the plan may say, and what to say back

“We cannot discuss this member with you.” I understand. What form do you need from the member so that I can act for them? Please send it, and tell me whether you can accept it by fax or online.

“The member must call us.” The member is unwell and has asked me to help. Can the member give permission on a three-way call, and do you also need it in writing?

“We need a power of attorney.” Which kind, and is the plan’s own form enough? Please tell me in writing what you will accept.

The three-way call script helps with these calls.

The rule

A plan’s claims procedure must allow an authorized representative to act on behalf of a claimant in pursuing a benefit claim or appeal. In a claim involving urgent care, the plan must allow a health care professional with knowledge of the claimant’s medical condition to act as authorized representative. See Code of Federal Regulations (CFR), title 29, section 2560.503-1(b)(4).

Watch for

• What is not covered here. This page does not cover powers of attorney, guardianship, children, or what to do if the person has died. Ask the plan what it needs, and ask a legal aid office. See legal aid.
• Permission is not unlimited. Read what the form lets you do, and how long it lasts.
• A paid helper. If you are hiring someone to act, see paying for help.
• A doctor’s office. It can help in other ways too. See support a patient’s appeal.

What next

• Patient appeal and provider appeal: run both: how to work with the office.
• Medicare counseling: free help for someone with Medicare.
• Help someone else with their denial: all the pages on this topic.