Form revised 10/1/2019
U.S. Virgin Islands
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 Benefici
2a. Medicare Number:______________________
2b. Claim Number (ICN/DCN if available):______________________
3. Provider Name:________________
4. Person Appealing: Beneficiary Provider of Service Representative
5. Address of the Person Appealing:
City_________________________ State_______ ZIP C
5a. Telephone Number of the Person Appealing:_________________________
5b. Email Address of the Person Appealing:_______________________
6. Item or service you wish to appeal:______________
Date of the servi
From_______________________ To________________________
8. Does this appeal involve an overpayme
nt? 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
Number 09302
Redetermination Number