Did you know that a beneficiary or supplier can appoint a representative to act on their behalf for requesting an appeal? Besides, they may appoint them at any time in the appeals process.
But, do you know how one can appoint a representative? Well, simply by completing and submitting an Appointment of Representative (AOR) form.
This guide will discuss everything you need to know about it, from its role in medical billing to common challenges.
That’s not all, we will also explain how to fill out the CMS-1696 form to handle Medicare claims, appeals, grievances, or coverage requests. So, continue reading!
AOR’s Role in Medical Billing
The AOR in medical billing serves many purposes. Some of these are listed below:
Streamlines Claim Processing
It enables healthcare providers to bill insurance carriers for the rendered services. This helps accelerate claim processing and minimize administrative barriers.
Centralized Communication & Authority
The appointed representative acts as the primary point of contact for Medicare. That is, you have the authority to make requests and receive all communications related to a medical claim or grievance.
Regulatory Fee Oversight
It ensures that all representation fees are approved by the Secretary of Health and Human Services (HHS). The outcome? It helps maintain fair and reasonable pricing.
Accelerated Claims Processing
As an appointed representative, you have the authority to present evidence and arguments to support an appeal during the adjudication process.
Facilitation of Financial Waivers
It also facilitates the signing of required waivers. For example, when a healthcare provider represents a patient, they must waive the right to collect payment if a service is deemed non-covered.
Authorized Information Access
It authorizes the representative to view the patient’s personal medical information necessary for the case.
Period of Validity
The AOR form remains valid for one year from the date of signature or for the entire duration of the specific claim or appeal for which you file it.
Appointment of Representative (AOR) Form Usage
In the previous section of this guide, we explained the role of an AOR form in detail. However, you must submit this form to ensure a successful appointment.
Let’s review a real-world scenario to better understand the usage of the AOR form in medical billing:
Picture a patient who received a denial for a specialized surgical procedure. However, the physician believes that the denial was an error.
Thus, the patient completes the form (CMS-1696) to appoint the provider’s billing manager as their representative.
How Does It Work?
- The patient authorizes the billing manager to act as their legal agent by signing the form.
- The billing manager is now legally permitted to view the patient’s private medical records and previous claim history.
- The insurance carrier updates its records to ensure all future correspondence, evidence requests, and the final decision letter are sent directly to the billing manager instead of the patient.
How to Fill Out the Appointment of Representative Form?
Now that you know what purpose the AOR form serves, it is time to understand how to fill it out for the successful appointment of a representative:
Section 1: Information About the Person Appointing the Representative
This section of the CMS-1696 form must be completed and signed by the patient, healthcare provider, or the person who wants to be represented:
| Field Name | Description |
|---|---|
| Name | Write the full name of the person who wants to appoint a representative. |
| Medicare number or NPI | Provide the NPI (for providers/suppliers) or Medicare beneficiary number (for patients)\. If neither applies, simply mention not applicable. |
| Mailing address | Enter the full street address, including the ZIP code, city, and state of the person who is appointing the representative. |
| Phone number | Provide a valid phone number with the area code. |
| Fax (optional) | Enter your fax number if available. |
| Email (optional) | You may also provide your email address. |
| Signature | The person appointing the representative must sign the AOR form. |
| Date signed | Mention the date of form signing in MM/DD/YYYY format. |
Section 2: Information About the Representative
The individual who is accepting the responsibility to act on the other person’s behalf must complete this part of the form, CMS-1696 appointment of representative:
| Field Name | Description |
|---|---|
| Representative name | Mention the full name of the person who will act as the representative. |
| Professional status or relationship | Clarify how the representative is related to the person in Section 1, e.g., friend, daughter, attorney, etc. Or you can enter your professional status. |
| Mailing address | Write the representative’s full street address, including city, state, and ZIP code. |
| Phone number | Provide the representative’s phone number with the area code. |
| Fax (optional) | You can also provide the representative’s fax number if they have one. |
| Email (optional) | You may also share the representative’s email address to ensure effective communication. |
| Signature | The representative must sign here to certify they are eligible to act as a representative. Besides, this certifies that they have not been prohibited, suspended, or disqualified from practice before the Department of Health and Human Services (HHS). |
| Date signed | Enter the date the representative signed the AOR form in MM/DD/YYYY format. |
Section 3: Waiver of Fee for Representation
You should use this section for the appointment of a representative form only if the representative agrees not to charge for their services:
| Field Name | Description |
|---|---|
| Signature | The representative’s signature is mandatory here if: (1) the representative is a provider or supplier who provided the services at issue, OR (2) if any other representative voluntarily chooses to waive their fee. |
| Date signed | The date the waiver was signed in MM/DD/YYYY format. |
Section 4: Waiver of Payment for Items or Services at Issue
This part of the AOR form is specific to suppliers or providers representing a patient in an appeal:
| Field Name | Description |
|---|---|
| Signature | The signature is required if the provider or supplier agrees to waive their right to collect payment from the patient for specific items or services (in the event Medicare denies coverage during the appeal). |
| Date signed | The date the payment waiver was signed in MM/DD/YYYY format. |
Challenges Related to AOR Form
Discussed below are some of the key challenges related to the AOR in medical billing:
- The appointed representative is only valid for one year from the date of the last signature. Thus, you must ensure diligent tracking to avoid expiration during lengthy multi-level appeals.
- Errors in Medicare numbers or NPIs can stall the entire adjudication process.
- You must send the form to the specific location handling the claim or appeal. However, it can be confusing when dealing with multiple Medicare Administrative Contractors (MACs).
- Since the providers who act as representatives cannot charge for the services, they must bear the appeal-related administration costs.
- What happens when a non-provider representative, such as an external attorney, wants to charge a fee? They must navigate a complex approval process through the Secretary of HHS.
Form SSA-1696 vs. Form CMS-1696
The table below offers an at-a-glance view of the key differences between SSA-1696 and CMS-1696 forms:
| Form CMS-1696 (Appointment of Representative) | Form SSA-1696 (Appointment of Representative) | |
|---|---|---|
| Agency | Centers for Medicare and Medicaid Services (CMS). | Social Security Administration (SSA). |
| Primary Use | Medicare claims, appeals, grievances, or coverage requests. | Disability claims (SSDI/SSI), retirement, and survivors’ benefits. |
| Representative’s Role | Acts as the main contact for specific medical claim disputes or insurance appeals. | Helps with initial applications, hearings before an administrative law judge (ALJ), and benefit calculations. |
Note that both forms are used to appoint a representative. However, they belong to different federal agencies and are used for different types of cases.
Partner With MediBillMD
To summarize, CMS-1696 AOR form authorizes a representative to act on behalf of a beneficiary in Medicare appeals. Simply put, it grants authority to present evidence, access medical records, and receive communications.
If you do not have the resources or time to handle billing operations in-house, feel free to outsource medical billing services to professionals at MediBillMD.
