Curing a Defective Appointment of Representative

270.1.6 - Curing a Defective Appointment of Representative (Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) If any of the required elements listed in §270.1.2 are missing, the appointment of representative form is considered defective. How a MAC handles these situations depends on the party attempting to make an appointment. When the beneficiary attempts to make the appointment, the MAC provides assistance to the beneficiary and representative in securing the appointment, based on the time frames set forth below. When a provider or physician or other supplier attempts to make the appointment, the MAC provides instruction on the proper and timely completion of the appointment. Where an adjudication time frame applies, the time from the later of the date that a defective appointment of representative was filed or the current appeal request was filed by the prospective appointed representative, to the date when the defect was cured, the party notifies the adjudicator that he or she will proceed with the appeal without a representative, or the 30-day deadline for curing the defect has elapsed with no response, does not count towards the adjudication time frame. The following provides guidance on properly responding to a representative’s attempt to submit a request for appeal. A. Missing or Defective Appointment When a Beneficiary is the Represented Party 1. Defective Appointment of Representative When an individual is attempting to act as a beneficiary’s representative, but submits an incomplete or defective appointment instrument, the MAC shall advise the individual of how to complete the appointment, and shall notify the individual to submit the completed appointment to the MAC within 30 calendar days. The MAC shall advise the individual of what corrections are required to execute a valid appointment and that a decision letter will not be sent to the individual unless a valid appointment is executed. Should the appointment instrument not be corrected within 30 calendar days, the MAC proceeds with processing and rendering a decision on the appeal, unless there is evidence or information to indicate the appeal was not submitted at the request of the beneficiary. It sends the appeal decision to the beneficiary and any other party to the appeal, but not to the individual attempting to act as the beneficiary’s representative. This will ensure that the beneficiary receives an appeal decision when it appears that the appeal originated with the beneficiary or was submitted with the beneficiary’s knowledge and consent. When there is information or evidence that the appeal request and/or the appointment of representative instrument was not submitted at the request of the beneficiary, the MAC shall verify the beneficiary’s wishes with regard to the appeal (e.g., where more than one member of the beneficiary’s family has submitted an appeal or is attempting to act as representative for the beneficiary). In order to verify the wishes of the beneficiary, the MAC sends a letter to the beneficiary explaining the situation. The letter shall advise the beneficiary that in order to proceed with an appeal, a valid appointment instrument must be submitted within 30 calendar days. If no response is received within 30 calendar days then the appointment of representative will not be honored, and no redetermination will be performed. The MAC shall handle this as an inquiry. 2. Missing Appointment of Representative In cases of appeals filed on behalf of the beneficiary, the MAC need not develop an absent appointment of representative if the request for redetermination clearly shows the beneficiary knew of or approved the submission of the request for redetermination. It sends the appeal decision to the beneficiary and any other party to the appeal, but not to the individual attempting to act as the beneficiary’s representative. This will ensure that the beneficiary receives an appeal decision when it appears that the appeal was submitted with the beneficiary’s knowledge and consent. When there is information or evidence that the appeal request filed on behalf of the beneficiary was not submitted at the request of the beneficiary, the MAC shall verify the beneficiary’s wishes with regard to the appeal (e.g., where more than one member of the beneficiary’s family has submitted an appeal or is attempting to act as representative for the beneficiary but does not include an appointment instrument). In order to verify the wishes of the beneficiary, the MAC sends a letter to the beneficiary explaining the situation. The letter shall advise the beneficiary that a valid appointment instrument must be submitted within 30 calendar days in order to process the appeal. If no response is received within 30 calendar days, then the MAC does not conduct a redetermination. The MAC shall handle this as an inquiry. B. Defective or Missing Appointment When a Provider or Physician, Other Supplier, or Nonbeneficiary is the Represented Party 1. Defective Appointment of Representative In cases where the represented party is not a beneficiary, the MAC notifies both the individual attempting to be the representative and the party of the incomplete or defective appointment. The MAC explains why the appointment is defective, and describes the documentation or missing information that is required to complete the appointment. This may be done by telephone or written notification, and the method, time and date of any notification shall be documented in the case file. A corrected/completed appointment may be submitted to the MAC by mail, or at the MAC’s discretion by facsimile or (if available) secure Internet portal. The MAC allows 30 calendar days for the corrected appointment instrument to be submitted. Should the party fail to notify the MAC to proceed with the appeal without a representative, or the appointment instrument is not corrected within the time limit, the MAC dismisses the appeal request and sends a dismissal notice to the party (See §310.6.A.4). 2. Missing Appointment of Representative If an individual is attempting to act as a representative of a party that is not the beneficiary and fails to include an appointment instrument with the appeal request, the individual lacks the authority to act on behalf of the party, and is not entitled to obtain or receive any information related to the appeal. The MAC shall notify the individual that no redetermination will be performed until a valid request is received from the party or a valid appointment instrument is resubmitted with the redetermination request. The MAC shall handle this as an inquiry (see §310.1.B.5). C. Untimely Appeal Request Submitted With an Incomplete or Defective Appointment If an untimely-filed appeal request is submitted with an incomplete or defective appointment instrument, the MAC first determines if good cause for late filing exists (See §240). If the MAC finds that good cause for late filing exists, it follows the instructions contained in §270.1.6, above, prior to proceeding with the appeal request. If the MAC does not find good cause to extend the filing time limit, it dismisses the redetermination request. See §310.6.3 and §310.6.A.3. D. Untimely Appeal Request Submitted With a Missing Appointment 1. Missing Appointment when the Beneficiary is the Party If an untimely-filed appeal request is submitted by an individual attempting to represent a beneficiary and the request does not include an appointment instrument, the MAC first determines if good cause for late filing exists (See §240). If the MAC finds that good cause for late filing exists, it follows the instructions contained in §270.1.6.A.2. prior to proceeding with the appeal request. If the MAC does not find good cause to extend the filing time limit, it dismisses the redetermination request. (See §310.6.3 and §310.6.A.3.) 2. Missing Appointment When Provider or Physician, Other Supplier, or Nonbeneficiary is the Represented Party As explained in §270.1.6.B.2 above, if the individual lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, do not make a good cause determination; follow the instructions in §270.1.6.B.2. above.