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. A representative 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.