Providers should understand who may request an appeal, also known as a reconsideration, for a Medicare Advantage member.

Who May Request an Appeal?

An appeal may be submitted by:

• The member
• The member’s appointed or authorized representative, with appropriate documentation such as an Appointment of Representative (AOR) or other valid representative authority
• A party to the organization determination
• A treating physician requesting a standard pre-service reconsideration on the member’s behalf, after notifying the member
• The member or a physician acting on the member’s behalf when requesting an expedited reconsideration

CMS regulations specifically allow a treating physician to request certain pre-service reconsiderations on behalf of a member. 

What About NPs and PAs?

CMS's physician-specific reconsideration provision does not expressly include Nurse Practitioners (NPs) or Physician Assistants (PAs). If an NP or PA is submitting an appeal as the member’s representative, appropriate documentation establishing that representative authority should accompany the appeal. (Appointed or Authorized representative Form)

Provider Tip

Before submitting an appeal on behalf of a member, confirm that the person submitting the request has the appropriate authority to do so.

If the individual does not independently qualify to request the appeal, documentation establishing their authority to represent the member will be needed before the request can be processed as a member appeal.