CMS Pub. 100-04, ch. 30, § 400.3.6

The MOON may be delivered to a beneficiary’s appointed representative. Appointed

representatives are individuals designated by beneficiaries to act on their behalf. A

beneficiary may designate an appointed representative via the “Appointment of

Representative” form, the CMS-1696. http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf. See Chapter 29 of the Medicare Claims Processing

Manual, section 270.1, for more information on appointed representatives.

The MOON may also be delivered to an authorized representative. Generally, an

authorized representative is an individual who, under State or other applicable law, may

make health care decisions on a beneficiary’s behalf (e.g., the beneficiary’s legal

guardian, or someone appointed in accordance with a properly executed durable medical

power of attorney).

Notification to a beneficiary who has been deemed legally incompetent is typically made

to an authorized representative of the beneficiary. However, if a beneficiary is

temporarily incapacitated, a person (typically, a family member or close friend) whom

the hospital or CAH has determined could reasonably represent the beneficiary, but who

has not been named in any legally binding document, may be a representative for the

purpose of receiving the MOON. Such a representative should act in the beneficiary’s

best interests and in a manner that is protective of the beneficiary and the beneficiary’s

rights. Therefore, a representative should have no relevant conflict of interest with the

beneficiary.

In instances where the notice is delivered to a representative who has not been named in a

legally binding document, the hospital or CAH annotates the MOON with the name of

the staff person initiating the contact, the name of the person contacted, and the date,

time, and method (in person or telephone) of the contact.

NOTE: There is an exception to the in-person notice delivery requirement. If the

MOON must be delivered to a representative who is not physically present to receive

delivery of the notice, the hospital or CAH is not required to make an off-site delivery to

the representative. The hospital or CAH must complete the MOON as required and

telephone the representative.

• The information provided telephonically includes all contents of the MOON;

• Note the date and time the hospital or CAH communicates (or makes a good faith

attempt to communicate) this information telephonically, per 400.2 above, to the

representative is considered the receipt date of the MOON;

• Annotate the “Additional Information” section to reflect that all of the

information indicated above was communicated to the representative; and

• Annotate the “Additional Information” section with the name of the staff person

initiating the contact, the name of the representative contacted by phone, the date

and time of the telephone contact, and the telephone number called.

Mail a copy of the annotated MOON to the representative the day telephone contact is

made.

A hard copy of the MOON must be sent to the representative by certified mail, return

receipt requested, or any other delivery method that can provide signed verification of

delivery (e.g., FedEx, UPS). The burden is on the hospital or CAH to demonstrate that

timely contact was attempted with the representative and that the notice was delivered.

If the hospital or CAH and the representative both agree, the hospital or CAH may send

the notice by fax or e-mail; however, the hospital or CAH’s fax and e-mail systems must

meet the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy

and security requirements.