CMS Centers For Medicare and Medicaid Services Logo Medicare Secondary Payer Recovery Portal

Authorization Documentation

Print this page Print this page   |   Close

This page provides you with the ability to view all authorizations that have been submitted for the case as well as submit a new authorization.  

The Centers for Medicare & Medicaid Services (CMS) will allow an individual or entity to have access to a Medicare beneficiary’s personal information only if the Medicare beneficiary has provided this authorization to CMS in writing.  The two types of authorizations are Proof of Representation and Consent to Release.  For a complete description of each authorization type, please see the applicable help pages found at the following links: What is Consent to Release?    What is Proof of Representation?

Current Authorizations on File

The top section of the Authorization Documentation page displays a list of all authorizations that have been submitted to date for the case.    They will be listed chronologically with the most current authorization listed first.  For each submitted authorization, the following information will display:

Field

Description

Authorization Type

The type of authorization submitted.  It can be:  Proof of Representation or Consent to Release. 

Status

Current status of the submitted authorization.    It can be Verified, Unverified, or Invalid.  For a complete description of each authorization status, view the help page found at the following link:  Authorization Status Definitions? Note:  You will not be able to receive correspondence until your authorization is in a Verified status. 

Start Date

The date the authorization goes into effect.

End Date

The date the authorization terminates. 

 

 

Submit New Authorization

 

The authorization process begins when a Proof of Representation or Consent to Release document has been submitted to CMS for the Medicare beneficiary and concludes once the authorization has been verified.   The next section of the Authorization Documentation page enables you to submit a new authorization and upload the necessary supporting documentation that backs up your request.  The information entered on this page must match the information submitted on your supporting documentation.   

 

In order to submit a new authorization, you must perform the following steps:

 

1.    Select the authorization type by clicking the radio button next to the desired authorization (see example in Figure 1). 

 

Figure 1.

 

2.    Select the representation type for the individual or entity requesting authorization. First click the down arrow in the selection box and then click the appropriate representation type (see Figure 2) from the list that displays. 

 

Figure 2.

 

An explanation of each representation type is as follows:

·   Attorney - A person licensed to practice law.

·   Guardian/Conservator – Appointed by a judge once it is determined that the beneficiary is incapacitated.

§  Guardian - a person responsible for the beneficiary’s personal affairs.

§  Conservator - a person responsible for managing the beneficiary’s estate and financial affairs.  

·   Power of Attorney - A legal document giving the beneficiary's representative full legal authority to preside on the beneficiary's behalf.

·   Third Party Administrator - An entity hired to act on behalf of and/or represent an organization or person for a specific matter such as the recovery of a Medicare overpayment.  For example, a workers’ compensation carrier may hire an "agent" to assist during the Medicare recovery process and provide a Proof of Representation document allowing that agent to act on their behalf in regard to that specific case.

·   Individual/Other – All other types not covered by any of the other descriptions.

 

3.    Enter the Authorization Start Date and Authorization End Date (if applicable). 

·        Authorization Start Date: The date the authorization goes into effect.  This field is required.  It must be entered in MMDDCCYY format and it cannot be a future date.  If the supporting documentation does not specify a start date, enter the date the authorization was signed by the beneficiary/representative. 

·        Authorization End Date: The date the authorization terminates.    If the supporting documentation does not specify a termination date, this field must be left blank.  If the supporting documentation specifies a termination date for the authorization, you must enter that date.   If this date is entered, it must be entered in MMDDCCYY format.   

 

4.    Upload required documentation that supports the type of authorization requested.    See below for a list of the Supporting Documentation Requirements.    Once you are ready to upload your documentation, click [Upload Documentation].   This will take you to the Documentation Upload page where you will perform the upload.    

Supporting Documentation Requirements

 

Consent to Release

Required information:

·   The Medicare beneficiary’s name exactly as shown on their red, white, and blue Medicare card;

·   Medicare Health Insurance Claim Number (Medicare ID)of the Medicare beneficiary exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 123456789A);

·   Name of individual or entity to which the information may be disclosed;

·   When to start the request for authorization; 

·   When to terminate the request for authorization (if applicable);

·   Signature of the Medicare beneficiary or the beneficiary’s representative; and

·   Date the Medicare beneficiary signed the Consent to Release.

If you are requesting authorization for a deceased beneficiary, you must include a copy of the legal documentation which confirms that you can sign or speak on the beneficiary’s behalf.  For example, you can include:

·   Executor/Executrix papers;

·   Next of kin attested by court documents with a court stamp and a judge’s signature;

·   Letter of Testamentary or Administration with a court stamp and judge’s signature;

·   Personal representative papers with a court stamp and judge’s signature;

·   Birth certificate;

·   Marriage license;

·   Death certificate; or

·   Signed/notarized statement.

Proof of Representation (POR)

Required information:

A copy of a Retainer Agreement (i.e., an agreement between a client and his or her lawyer that spells out the terms of the business arrangement between them) will be accepted as Proof of Representation.

Required information if you are submitting a Retainer Agreement:

·   Retainer Agreement on attorney letterhead or accompanied by a cover letter on letterhead;

·   Beneficiary name (printed on the agreement or cover letter);

·   Signature of beneficiary;

·   Date of signature of beneficiary;

·   Signature of attorney; and

·   Date of signature of attorney.

Required information if you are not submitting a Retainer Agreement: 

·   The Medicare beneficiary’s name exactly as shown on their red, white, and blue Medicare card;

·   Medicare Health Insurance Claim Number (Medicare ID) of the Medicare beneficiary exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 123456789A);

·   Representation type  (i.e., Attorney, Guardian/Conservator, Power of Attorney, Third Party Administrator, Individual/Other);

o   If the Proof of Representation is for a Third Party Administrator, the Proof of Representation must also include a letter on the insurer’s letterhead that contains:

§  A beneficiary specific statement (including the beneficiary’s name and Medicare ID) on the insurer or workers’ compensation entity’s letterhead that the agent is representing the insurer or workers’ compensation carrier with respect to a claim involving the identified Medicare beneficiary;

§  Name(s) of person(s) that have been hired; and

§  A statement as to what they are approved to do.

·   Firm/company name (if applicable);

·   Signature of beneficiary;

·   Date of signature of beneficiary;

·   Name of representative/attorney;

·   Signature of representative/attorney; and

·   Date of signature of representative/attorney.

 

Note:  If the beneficiary is incapacitated, you must also include a court document appointing power of attorney to confirm that you can sign the Proof of Representation or speak on the beneficiary’s behalf.

 

5.    After you have uploaded all required files on the Documentation Upload page, click [Continue].  You will be returned to the Authorization Documentation page.   Verify that the correct files have been uploaded (See Figure 3, A).

a.    If an incorrect file has been uploaded, click [Delete] (See Figure 3, B).   This will remove the file and it will not be uploaded to the case.

b.    If you do not want to add any of the files to the case, click [Cancel].  The files will not be submitted for the case and you will be returned to the Case Information page. 

 

6.    Once you have confirmed that all uploaded files should be submitted for the case, click [Continue] to complete the submission process.  You may [Print this Page] for your records.   The Authorization Documentation Confirmation page will display.

 

Figure 3

 

 

Please allow 45 days for CMS to review the supporting documentation and validate the authorization.   Do not attempt to resubmit the same authorization more than once.   If you attempt to submit a duplicate authorization (the same authorization type for the same time period), you will receive the following message “Duplicate Authorization already on file.”

 

Revoke, Delete or Change a Verified Authorization

To revoke, delete, or change the start and/or end dates on an existing Verified authorization, you must submit your request in writing to:

 

Liability Insurance, No-Fault Insurance, Workers’ Compensation: NGHP

PO Box 138832

Oklahoma City, OK 73113

Fax: (405) 869-3309