Appointment of Representation

In accordance with regulations established by the Centers for Medicare & Medicaid Services (CMS), the member's authorized representative may submit a request for an appeal, file a grievance and obtain an organization determination on behalf of the member. An appointment of representation (AOR) may be in the form of a signed written authorization or through legal documentation, for example, a court-ordered guardianship or conservatorship, durable power of attorney or health care power of attorney.

If a member requests that their representative file an appeal on the member's behalf, the member must provide a written statement formally appointing the individual to act as their representative in filing the appeal. Once the written authorization is received and recorded by Health Net or the participating provider, the representative may obtain information about the member's claim or request for service, submit evidence, make statements about facts and law, and make any request or receive any notice regarding the proceedings to the same extent as the member. The authorized representative has the same legal rights as the member regarding the appeal.

The AOR form - English (PDF) (AOR form - Spanish (PDF)) appointing an authorized representative must include the following:

• Member's name, address and telephone number.
• Medicare identification (ID) number.
• Member's signature and date.
• Representative's signature and date, accompanied by a statement that the individual accepts the appointment as representative (if an attorney is representing the member, only the member's signature is required).
• Name, address and telephone number of the individual being appointed representative
• A statement that the member authorizes the representative to act on the member's behalf for the claims at issue, and a statement authorizing disclosure of individually identifying information to the representative.

All notices or other correspondence intended for the member must be sent to the member's representative instead of the member.

The following are examples of special circumstances when an AOR form is not necessary:

• If a member has a court-appointed guardian or health care proxy under state law.
• If a member is not physically or mentally competent to sign an AOR form.
• If a physician requests an expedited review on behalf of a member.
• If a treating physician, upon notifying the member, acts on behalf of the member.
• If an estate representative submits an appeal request on behalf of a deceased member. In this case, obtain a copy of the order appointing the estate representative before opening the appeal case. If the documentation is unavailable, and the representative is an immediate family member, the appeal case may be opened.

Once an appeal is initiated, the party who initiated the appeal may withdraw it. The withdrawal request must be in writing. The member should be contacted to determine whether they agree with the request to rescind the appeal and, if they agree, the request must be in writing.