DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE RECONSIDERATION REQUEST FORM — 2nd LEVEL OF APPEAL
1.
Beneficiary’s name:
2.
Medicare number:
3.
Item or service you wish to appeal:
4.
Date the service or item was received:
5.
Date of the redetermination notice (please include a copy of the notice with this request): (If you received your
redetermination notice more than 180 days ago, include your reason for the late filing.)
5a. Name of the Medicare contractor that made the redetermination (not required if copy of notice attached):
5b. Does this appeal involve an overpayment?
(for providers and suppliers only)
Yes No
6.
I do not agree with the redetermination decision on my claim because:
7.
Additional information Medicare should consider:
8.
I have evidence to submit. Please attach the evidence to this form or attach a statement
explaining what 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 reconsideration.
I do not have evidence to submit.
9.
Person appealing: Beneficiary Provider/Supplier
Representative
10.
Name, address, and telephone number of person appealing:
11.
Email of person appealing (optional):
12.
Date of appeal (optional):
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 83 Fed. Reg. 6591
(2/14/2018) or
at https://www.hhs.gov/foia/privacy/sorns/cms-sorns.html
Form CMS-20033 (07/19)
