Form Cms-20031 - Transfer (Assignment) Of Appeal Rights (Page 2 of 2) in pdf

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

Form CMS-20031 (05/05) EF 05/2005

Form Cms-20031 - Transfer (Assignment) Of Appeal Rights Page 2