You, your appointed representative or your physician can submit a request for a determination.
- If you need assistance understanding or following the determination process, you can get assistance from a friend, lawyer or someone else. There are groups, such as legal aid services, that can help you find a lawyer or give you free legal services, if you qualify.
- The individual can be a relative, provider, friend, or someone else.
- Give us your name, your Paramount identification number and written statement appointing an individual as your representative. You may use the Appointment of Representative form.
You may create your own form. It must include the following:
- Name, address, and telephone number of enrollee
- Enrollee’s Medicare Beneficiary Identifier (MBI)
- Name, address, and telephone number of the individual being appointed
- A statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative
- Is signed and dated by the enrollee making the appointment
- Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment, unless he/she is an attorney.
See Evidence of Coverage for a complete description of the guidelines that apply to the exceptions process.
Last updated: 09/30/2018