Fillable CMS20031 CMS 20031 Transfer of Appeal Rights

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CMS20031 CMS 20031 Transfer of Appeal Rights

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
TRANSFER OF APPEAL RIGHTS
Important: This form allows you to transfer your appeal rights to your health care provider for an item or
service. If your provider accepts your appeal rights, he or she cannot charge you for this item or service
(except for applicable coinsurance and deductible amounts) even if Medicare will not pay the claim. Please
see the back for more information before you complete this form.
Section I must be completed and signed by the beneficiary.
SECTION I: TRANSFER OF APPEAL RIGHTS
1. Name of Patient
(Please Print)
2. Medicare Number 3. Phone Number
(Include area code)
4. Address
(Street)
5. City 6.State 7.ZIP
8. Item or Service
9.
I, ___________________________________________________________, voluntarily transfer my
appeal rights to __________________________________________________. I understand that I will
have no right to appeal a denied claim for this item or service unless I cancel the transfer in writing. I
also understand that I cannot be charged for this item or service (except for applicable coinsurance and
deductible amounts) unless I cancel the transfer.
10. Signature
11.Date
Section II must be completed and signed by the health care provider or supplier.
SECTION II: ACCEPTANCE OF APPEAL RIGHTS
12.
I, _________________________________________________________________, accept the appeal
rights for the item or service listed Line 5. I will not collect payment from the patient for this item or
service, except for any applicable deductible or coinsurance.
13. Signature 14. Date 15. Phone Number
16. Address
(Street)
17.City 18.State 19.ZIP
Form CMS-20031 (03/18) EF 03/2018
See the back of this form for more information.
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
www.medicare.gov.
You have the right to get Medicare information in an accessible format, like large print, Braille, or
audio. You also have the right to file a complaint if you believe you’ve been discriminated against.
Visit https://www.cms.gov/about-cms/agency-Information/aboutwebsite/
cmsnondiscriminationnotice.html, or call 1-800-MEDICARE (1-800-633-4227) for more information.
Form CMS-20031 (03/18) EF 03/2018
2
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Completed 18 September 2019

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