DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
medicare redetermination request form — 1
LeveL of appeaL
st
Beneficiary’s name:______________________________________________________________________
1.
Medicare number: _______________________________________________________________________
2.
Item or service you wish to appeal: _________________________________________________________
3.
Date the service or item was received: _______________________________________________________
4.
Date of the initial determination notice (please include a copy of the notice with this request):
5.
(If you received your initial determination notice more than 120 days ago, include your reason for the late filing.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name of the Medicare contractor that made the determination (not required):
5a.
______________________________________________________________________________________
Does this appeal involve an overpayment?
Yes
No
5b.
(for providers and suppliers only)
I do not agree with the determination decision on my claim because:
6.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Additional information Medicare should consider:
7.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I have evidence to submit. Please attach the evidence to this form or attach a statement explaining what
8.
you intend to submit and when you intend to submit it. You may also submit additional evidence at a
later time, but all evidence must be received prior to the issuance of the redetermination.
I do not have evidence to submit.
Person appealing:
Beneficiary
Provider/Supplier
Representative
9.
Name, address, and telephone number of person appealing: ______________________________________
10.
______________________________________________________________________________________
Signature of person appealing: _____________________________________________________________
11.
Date signed:____________________________________________________________________________
12.
PRIVACY ACT STATEMENT: The legal authority for the collection of information on this form is authorized by section 1869 (a)(3) of the Social Security Act. The
information provided will be used to further document your appeal. Submission of the information requested on this form is voluntary, but failure to provide all or
any part of the requested information may affect the determination of your appeal. Information you furnish on this form may be disclosed by the Centers for Medicare
and Medicaid Services to another person or government agency only with respect to the Medicare Program and to comply with Federal laws requiring or permitting
the disclosure of information or the exchange of information between the Department of Health and Human Services and other agencies. Additional information about
these disclosures can be found in the system of records notice for system no. 09-70-0566, as amended, available at 71 Fed. Reg. 54489 (2006) or at
Form CMS-20027 (12/10)