Cms 20031 Form – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

TRANSFER OF APPEAL RIGHTS

Important: This form allows you to transfer your appeal rights to your health care provider for an item or service. If your provider accepts your appeal rights, he or she cannot charge you for this item or service (except for applicable coinsurance and deductible amounts) even if Medicare will not pay the claim. Please

see the back for more information before you complete this form.

Section I must be completed and signed by the beneficiary.

SECTION I: TRANSFER OF APPEAL RIGHTS

1. Name of Patient (PLEASE PRINT)

4. Address (STREET)

9. I, ___________________________________________________________, voluntarily transfer my

appeal rights to __________________________________________________. I understand that I will

have no right to appeal a denied claim for this item or service unless I cancel the transfer in writing. I also understand that I cannot be charged for this item or service (except for applicable coinsurance and deductible amounts) unless I cancel the transfer.

Section II must be completed and signed by the health care provider or supplier.

SECTION II: ACCEPTANCE OF APPEAL RIGHTS

12. I, _________________________________________________________________, accept the appeal

rights for the item or service listed Line 5. I will not collect payment from the patient for this item or service, except for any applicable deductible or coinsurance.

16. Address (STREET)

THIS INFORMATION MAY HELP ANSWER YOUR QUESTIONS ABOUT THIS FORM.

1.Why am I receiving this form?

A provider or supplier may not have the right to appeal in some situations, so they may ask you to transfer your appeal rights to them. This allows them to appeal on their own to Medicare.

2.What are my appeal rights?

You have the right to appeal if Medicare decides that they will not pay for an item or service. Your “appeal rights” are your rights to ask Medicare to reconsider their decision to not pay for the item or service.

3.What does it mean to transfer my appeal rights?

You have the right to transfer your appeal rights to your health care provider or supplier for an item or service. If Medicare decides not to pay for the item or service, your provider or supplier will be allowed to appeal the decision. You will not be able to appeal the decision; your provider must do it for you.

4.Who can I transfer my appeal rights to?

You may transfer your appeal rights only to the individual who provided the item or service that you listed in Section I of this form.

5.What financial risks do I take when I transfer my appeal rights?

If a provider or supplier accepts your appeals rights, they cannot bill you for the item or service, unless you cancel the transfer or you already signed an Advance Beneficiary Notice. Whether or not you choose to transfer your appeal rights, you will be responsible for paying the appropriate deductible or coinsurance amounts.

6.Am I transferring my appeal rights for all of my claims?

No, you are only transferring your appeal rights for the item or service that you listed in Section I of this form.

7.How long does the transfer last?

This transfer is permanent, unless you decide to cancel it. However, if you cancel the transfer, you may be responsible for payment if Medicare decides that they will not pay for the item or service.

8.How can I cancel the transfer?

You can cancel the transfer by indicating in writing that you no longer wish to transfer your appeal rights for this item or service. You can do this at any time. For information about canceling the transfer, call 1-800-MEDICARE (1-800-633-4227).

9.Who can I contact if I need help completing this form?

State Health Insurance Assistance Programs (SHIPs) are located in every State. These programs have volunteer counselors who can give you free assistance with Medicare questions. Please check your Medicare and You handbook to locate a program in your State. Or, for more information, visit www.medicare.gov.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you believe you’ve been discriminated against. Visit https://www.cms.gov/about-cms/agency-Information/aboutwebsite/ cmsnondiscriminationnotice.html, or call 1-800-MEDICARE (1-800-633-4227) for more information.

Form CMS-20031 (03/18) EF 03/2018

2