Authorized Representative

Appointing a Representative – Instructions & Form

A member can give okay to another adult person (like a relative, friend, lawyer, or doctor) to act as his or her representative to file a complaint or appeal or to request a coverage determination on his or her behalf.

A representative can also be approved by the court or act on behalf of the member to file an appeal or complaint on their behalf. Representatives can include, but is not limited to, a court ordered guardian, a person who has Durable Power of Attorney, a health care proxy, or a person chosen under a health care consent statute.

If a member is incapacitated or legally incompetent a representative is not required to submit an Appointment of Representation (AOR) Form. The representative will need to give Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) copies of the legal papers supporting his or her status as the member’s authorized representative.

How to Authorize a Representative:

  • The member must sign, date and fill out a representative form.
  • The person acting on behalf of the member must sign, date and fill out the same form.
  • Download the CMS-1696 form ,complete it, and mail it to:

Superior Health Plan STAR+PLUS Medicare-Medicaid Plan (MMP)
5900 E. Ben White Blvd.
Austin, TX 78741

Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) requires a copy of the completed and signed Appointment of Representative (AOR) Form to move forward with appeals or complaints filed by the member’s representative.

  • The form will be valid during the entire appeal or complaint process.
  • The Appointment of Representative (AOR) Form is valid for one year from the date on the form. A member can cancel the Form at any time.

For more information, call Member Services at 1-866-896-1844. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711. 

 

Last Updated: 10/01/2016
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