Can I appeal a denial for a family member?
Yes, as their authorized representative. Every plan must accept a signed authorization naming you, and once it is on file the plan must send you the notices and talk to you about the claim; for an urgent care claim a treating provider can act as representative without a form.
What to do, in order
- Step 1
Get the plan's representative form
Ask the plan for its authorized-representative or appointment-of-representative form. If it has none, a signed and dated letter from the member naming you, with the member ID and claim number, is enough under ERISA and ACA rules.
- Step 2
Add a HIPAA authorization
The representative form covers the claim; a HIPAA authorization lets the plan and the providers release records to you. Use the plan's form or a plain signed authorization that names the records and the recipient.
- Step 3
File the appeal in the member's name
The appeal is the member's; you sign as representative. Keep the deadline that applies to the member's notice.
- Step 4
For urgent care, do not wait for the form
A health care professional with knowledge of the member's condition can act as representative on an urgent care claim without a signed authorization.
The deadline that applies
The member's deadline applies: at least 180 days from the denial on ERISA and ACA plans (29 CFR 2560.503-1; 45 CFR 147.136); 65 days from the notice on Medicare Advantage and Part D (42 CFR 422.582, 423.582). The representative form does not extend it, so file the appeal first and the form with it.
Calculate your date →Documents to gather
- The signed authorized-representative form or letter
- A HIPAA authorization naming you
- The member's denial notice and ID
- For Medicare: form CMS-1696 if the plan asks for it
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Related questions
Can a parent appeal for an adult child?
Only with the child's signed authorization, unless the parent holds a power of attorney or guardianship.
Can the doctor's office appeal instead?
Providers can file their own appeals under their contract and can be named as the member's representative. Both can run at once.
What if the member cannot sign?
A durable power of attorney, guardianship order, or the plan's incapacity procedure. Ask the plan what it accepts.
Sources
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