APPOINTMENT OF REPRESENTATIVE (AOR) FORM WAIVER OF PAYMENT

Although any party can pursue a claim or an appeal on their own, some may wish to seek the assistance of another person. A beneficiary may appoint another individual to represent them in dealings with the contractor. This representative may be appointed at any point in the appeals process.

Possible representatives may include (but are not limited to):

• Family member of the beneficiary
• Friend or neighbor of the beneficiary
• Member of a provider, supplier or physician group
• Surrogate decision maker for an incapacitated beneficiary
• Attorney
• Congressional staff members
• Member of a beneficiary advocacy group

A specific individual must be named as the representative rather than an organization or entity. This ensures that any confidential beneficiary information is only released to the individual intended to receive it by the beneficiary. The appointment of a representative is valid for one year from either the date it is signed by the beneficiary or the date the appointment is accepted by the representative, whichever is later.

In order to name a party as a representative, the beneficiary and the individual accepting the appointment must either complete an Appointment of Representative form or submit a written statement. The following information must be included on the Appointment of Representative Form or written statement:

• Name/Address/Phone number of the beneficiary
• Beneficiary's Health Insurance Claim Number
• Name/Address/Phone number of the individual being appointed as representative
• Dated statement indicating that the beneficiary authorized the representative to act on their behalf for the claim in question
• Dated statement that the representative accepts the appointment
• Dated statement indicating that the representative waives his/her right to charge and collect a fee for representing the beneficiary

The representative must sign the appointment form or a written statement within 30 calendar days of the date the beneficiary signs it. The appointment remains valid for one year unless the beneficiary specifically withdraws the representative's authority. If the appointment of representative form is found to be valid, it remains valid for all subsequent levels of appeal.

If the beneficiary is living, but unable to sign the Appoint of Representative form him/herself, only an authorized individual may sign for him/her. An “authorized” individual may be one of the following:

• A spouse, child or sibling may sign on behalf of the beneficiary. The individual must submit a brief statement describing his or her relationship to the beneficiary and explain why the beneficiary is unable to sign.
• A legal guardian may sign on behalf of the beneficiary. A copy of the document granting guardianship must be included with the Appointment of Representative form.
• A legal power of attorney may sign on behalf of the beneficiary. A copy of the document naming the individual as POA must be included with the Appointment of Representative form. Note: The Power of Attorney becomes void upon the death of the principle.

If the beneficiary is deceased, the appeal request may be filed by the legal representative of the estate. If there is no legal representative, it may also be filed by any person who has assumed responsibility for settling the decedent's estate. In this situation, there must be proof that the person has assumed responsibility for settling the estate. This proof may be a copy of the will or probate court document.

WAIVER OF PAYMENT

The Waiver of Payment is a statement by the representative waiving their rights to payment from the beneficiary for non-covered services. It is intended to insure against conflict of interest. The statement must include:

• Representative name
• Service dates
• Beneficiary name
• Signature of the representative who signed the Appointment of Representative form HIC number
• Date of completion