Appeals Forms

Request an appeal

• What’s the form called?
  Redetermination Request (CMS-20027)

• What’s it used for?
  Requesting an appeal (redetermination) if you disagree with Medicare’s coverage or payment decision.

Request a 2nd appeal

• What’s the form called?
  Medicare Reconsideration Request (CMS-20033)

• What’s it used for?
  Requesting a 2^nd appeal (reconsideration) if you’re not satisfied with the outcome of your first appeal.

Request a 3rd appeal

• What’s the form called?
  Request for Administrative Law Judge Hearing or Review of Dismissal (OMHA-100)

• What’s it used for?
  Requesting a hearing by an Administrative Law Judge (ALJ) if you’re not satisfied with the outcome of your 2^nd appeal.

Choose someone to help you file an appeal

• What’s the form called?
  Appointment of Representative (CMS-1696)

• What’s it used for?
  Giving another person legal permission to help you file an appeal.

Give your provider or supplier appeal rights

• What’s the form called?
  Transfer of Appeal Rights (CMS-20031)

• What’s it used for?
  Transferring your appeal rights to your provider or supplier so they can file an appeal if Medicare decides not to pay for an item or service.