Form Cms 20027 PDF Details

Navigating the Medicare system can often feel like a daunting endeavor, especially when it comes to disputing coverage decisions. For individuals or providers dissatisfied with a Medicare determination, the CMS 20027 form serves as a vital tool, enabling a formal request for reconsideration or the first level of appeal. This form, issued by the Department of Health and Human Services and managed by the Centers for Medicare & Medicaid Services, is designed to ensure that beneficiaries and providers have a clear and structured pathway to challenge decisions regarding item or service coverage. It requires detailed information such as the beneficiary’s name, Medicare number, the specific item or service under dispute, and the initial determination notice, among other critical pieces of evidence to support the appeal. Moreover, it includes sections to articulate the disagreement with the original decision and to submit any additional information that could influence the redetermination. The process for submitting this form is backed by legal mandates under the Social Security Act, emphasizing its significance in the Medicare appeal process. Failure to provide comprehensive documentation or adhering to the guidelines can impact the success of the appeal, underscoring the form's importance in safeguarding the rights of Medicare recipients and providers. Notably, this form also highlights stipulations for privacy and the lawful use of submitted information, ensuring that appellants’ details are handled with the utmost care and confidentiality, solely in the interest of resolving the appeal in accordance with federal regulations.

QuestionAnswer
Form NameForm Cms 20027
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescms, form cms 20027, pdf, 20037

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE REDETERMINATION REQUEST FORM — 1ST 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 initial determination notice (please include a copy of the notice with this request):

(If you received your initial determination notice more than 120 days ago, include your reason for the late filing.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

5A. Name of the Medicare contractor that made the determination (not required):

______________________________________________________________________________________

5B. Does this appeal involve an overpayment?

Yes

No

(for providers and suppliers only)

 

 

6.I do not agree with the determination 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 redetermination.

I do not have evidence to submit.

9. Person appealing:

Beneficiary

Provider/Supplier

Representative

10. Name, address, and telephone number of person appealing: ______________________________________

______________________________________________________________________________________

11.Signature of person appealing: _____________________________________________________________

12. Date signed:____________________________________________________________________________

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 http://www.cms.gov/PrivacyActSystemofRecords/downloads/0566.pdf

FORM CMS-20027 (12/10)

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Stage number 1 of completing cms form 20027

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Best ways to fill in cms form 20027 portion 2

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