Fillable Form revised 10/1/2019: Puerto Rico Reconsideration Request Form (Medicare & Medicaid)

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Form revised 10/1/2019: Puerto Rico Reconsideration Request Form (Medicare & Medicaid)

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Form revised 10/1/2019
Puerto Rico
Reconsideration Request Form
Directions: If you wish to appeal this decision, please fill out the required information below and mail this form to the
address shown below. At a minimum, you must complete/include information for items 1, 2a, 6, 7, and 11 but to help us
serve you better; please include a copy of the redetermination notice with your request.
Submit requests to:
C2C Innovative Solutions Inc.
QIC Part B South
P.O. Box 45300
Jacksonville, FL 32232-5300
1. Name of Beneficiary:______________________________________________________________________________
2a. Medicare ID: _______________________________________________________________________________
2b. Claim Number (ICN/DCN if available):________________________________________________________________
3. Provider Name:___________________________________________________________________________________
4. Person Appealing: Beneficiary Provider of Service Representative
5.
Address of the Person Appealing:
Address_____________________________________________________
City_________________________ Stat
e_______ ZIP Code____________
5a. Telephone Number of the Person Appealing:______________
_____________________________________________
5b. Email Address of the Person Appealing:____________
__________________________________________________
6. Item or service you wish to appeal:___
_________________________________________________________________
7.
Dat
e of the ser
vice:
From_______________________ To________________________
8. Does this appeal involve an overpay
ment? Yes No
Please include a copy of the demand letter with your request.
9. Why do you disagree? Or what are your reasons for appeal? (255 character limit; attach additional pages if necessary.)
10. You may also include any supporting materials to assist your appeal. Examples of supporting materials include:
Medical Records Office Records/Progress Notes Copy of the Claim
Treatment Plan Certification of Medical Necessity
11. Printed Name of Person Appealing:
Contractor Number
09202
Redetermination Number
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Form revised 1012019: Puerto Rico Reconsideration Request Form (Medicare & Medicaid)

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Completed 10 January 2021

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