![]() Review your plan's Appeals and Grievances process in the Evidence of Coverage document.Īn appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.Click here to find and download the CMS Appointment of Representation form.You must include this signed statement with your appeal. ![]() Your representative must also sign and date this statement.(Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services." Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. ![]() You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
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