Appealing a Medicare PSOD decision

Normally, the right of appeal for a denial of PSOD under Part C rules belongs solely to the member. See the member process for appealing a denial.

However, CMS grants contracted providers the ability to appeal a denial on behalf of the member in two situations:

  1. Standard pre-service reconsiderations or appeals: A physician who is providing treatment to a member may, upon providing notice to the member, request a standard reconsideration or appeal on the member's behalf without submitting proof that the physician is the member's personal representative.
  2. Expedited reconsiderations: A contracted provider may appeal, on the member's behalf, a post-service denial for anything other than a dispute about the amount paid or billing denials. Provider must provide proof that he/she has been appointed the member's representative such as the Appointment of Representative CMS-1696 form. For payment or billing denials, contracted providers should follow the provider appeal process. For complete information on who may appeal see Chapter 13, Medicare Managed Care Manual.