You’ll need the CMS-20031 form if your healthcare provider will appeal Medicare’s denial of payment on your behalf.
What you’ll need:
• Basic information
• Medicare number
• Name of item or service
• Signature of Medicare enrollee
• Signature of healthcare provider
Other important information:
• You may only transfer your appeal rights to the healthcare provider who provided the service or medical item to you.
• Once your appeal rights have been transferred, you will no longer be able to directly appeal Medicare’s decision.
• The transfer is permanent unless you decide to cancel it, in which case you will become responsible for paying Medicare once again.
You may cancel the transfer by calling Medicare at 1-800-MEDICARE (1-800-633-4227).