CMS Pub. 100-04, ch. 29, § 270.2.3

The beneficiary making the transfer (assignor) and the provider or supplier accepting the transfer (assignee)

must complete the CMS standardized Transfer of Appeal Rights form (Form CMS-20031). This form is

entitled, “Transfer of Appeal Rights”. No alternative written instrument may be used. Signatures may

be handwritten, electronic, digital, and/or digitized. By signing the CMS-20031, the provider indicates

his/her acceptance of being the assignee. Page two of the form provides information to the beneficiary about

transferring appeal rights. The form CMS-20031 is available on the CMS.gov website at:

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20031.pdf

A. Completing a valid Transfer of Appeal Rights Form CMS-20031

Form CMS-20031, Transfer of Appeal Rights, is the required form that beneficiaries must use to assign their

appeal rights. Following are instructions for completing form CMS-20031.

1. Completing Section I - The name of the beneficiary transferring appeal rights must be clearly

legible. The beneficiary’s Medicare number must be provided in this section. This section includes

name, Medicare number, address and phone number, and the item or service that is at issue. The

beneficiary must provide a signature on the transfer statement and include the date. Only the

beneficiary may sign this section.

2. Completing Section II - “Acceptance of Appeal Rights” - The provider or supplier accepting the

appeal rights must complete this section. This section includes name, address, and phone number.

The provider or supplier must sign this section to accept the transfer of appeal rights and agree not to

collect payment (except for any applicable deductible or coinsurance) from the beneficiary for the

item or service at issue, unless a valid Advance Beneficiary Notice of Noncoverage (ABN) is in

effect.

If an incomplete form is submitted, the adjudicator should contact the party and provide a description of the

missing information. Unless the defect is cured, the provider or supplier lacks the authority to accept the

appeal rights of the beneficiary, and is not entitled to take action regarding the appeal or obtain or receive

any information related to the appeal, including the appeal decision. The adjudicator should not dismiss the

appeal request because the transfer of appeal rights is not valid.

CMS permits the use of a rubber stamp in lieu of a handwritten signature in accordance with the

Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a

CMS MAC of his or her inability to sign their signature due to their disability. By affixing the rubber stamp,

the person is certifying that they have reviewed the document.

B. Waiver of Right to Payment for the Items or Services at Issue

The provider or supplier who accepts the appeal rights must waive the right to collect payment from the

beneficiary for the item or service that is the subject of the appeal. The provider or supplier may collect any

applicable deductible or coinsurance. The provider or supplier agrees to this waiver by completing and

signing Section II of the Transfer of Appeal Rights form. The waiver to collect payment remains in effect

regardless of the outcome of the appeal decision.

This waiver remains valid unless the transfer is revoked by the beneficiary as described in subsection D,

below.

C. Duration of a Valid Transfer of Appeal Rights

Unless revoked, the transfer of appeal rights is valid for all levels of the appeal process including judicial

review, even in the event of the death of the beneficiary.

D. Revoking a Transfer of Appeal Rights

The party assigning their appeal rights may revoke the transfer of appeal rights by providing a written

statement of revocation to the adjudicator at any time. If revoked, the rights to appeal revert to the

beneficiary. The transfer may be revoked in the following ways:

1. In writing by the beneficiary. The revocation must be delivered to the adjudicator and the provider or

supplier and is effective on the date of receipt by the adjudicator.

2. By abandonment if the assignee does not file an appeal of an unfavorable decision to the financial

interests of the beneficiary.