Medicare Resources

Learn More About Medicare Policies and Procedures

The Centers for Medicare & Medicaid Services (CMS) is the agency of the U.S. Department of Health and Human Services that oversees the administration of federal healthcare programs. Contact CMS directly if you have a question or concern about your Medicare plan.

800-MEDICARE (800-633-4227)
TTY 877-486-2048

Centers For Medicare and Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850

www.medicare.gov

Medicare Policies and Procedures

Medicare Part C, also known as Medicare Advantage, allows qualifying members to leverage coverage for both medical and hospital services. The forms and resources below can help members manage their plans and access administrative services.

For Part C Grievances and Appeals, mail or fax statement letter to the Plan at:

Prominence Health Plan
Grievance and Appeals Department
1510 Meadow Wood Lane
Reno, NV 89502
Phone: 855-969-5882
Fax: 775-770-9004

For Part D Grievances, mail or fax statement letter to the Plan at:

Prominence Health Plan
Grievance Department
MedImpact Healthcare Systems
Appeals and Grievance
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858-790-6060
Phone: 844-587-7389

For Part D Appeals, mail or fax statement letter to the Plan at:

Prominence Health Plan
Appeals Department
MedImpact Healthcare Systems
Appeals and Grievance
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858-790-6060
Phone: 844-587-7389

For compliance or privacy concerns call:

Compliance Hotline
800-852-3449

Additional Plan Resources

Appointment of a Representative

Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form , must be submitted with the appeal and is valid for one year from the date. Both you and the appointed representative must sign the form. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.

The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:

Congressional staff members
Family members of a beneficiary
Friends or neighbors of a beneficiary
Members of beneficiary advocacy groups
Members of provider or supplier advocacy groups
Attorneys
Physicians or suppliers

The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.

The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative.

Instructions for completing the form:

The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
Completing Section I — ‘Appointment of Representative’ — A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
Completing Section II — ‘Acceptance of Appointment’ — The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
Completing Section III — ‘Waiver of Fee for Representation’ — This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal.
Completing Section IV — ‘Waiver of Payment for Items or Services at Issue’ — This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues described in section 1879(a)(2) of the Social Security Act.

If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision. The adjudicator will not dismiss the appeal request because the appointment of representative is not valid.

CMS Appointment of Representative Form (CMS Form-1696)
CMS Appointment of Representative Form (CMS Form-1696) (Spanish)

You can also call Member Services at 855-969-5882 (TTY: 711) to learn more about how to name your appointed representative. We are open October 1 through March 31 from 8 a.m. – 8 p.m., 7 days a week; and April 1 through September 30 from 8 a.m. – 8 p.m., Monday through Friday.

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Last update 9/14/2023

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