A redetermination must be requested in writing, and the request must be sent to the MAC that made the initial claim determination.
Days to file: the appellant has 120 days from the date of receipt of the initial claim determination to file a redetermination request.
Late filing: if you received your initial determination notice more than 120 days ago, include your reason for the late filing.
Appeal item: the item or service you wish to appeal, and the date the service or item was received (mm/dd/yyyy).
Contractor: name of the Medicare contractor that made the determination (not required).
Evidence: all evidence must be received prior to the issuance of the redetermination.
| Question | Answer |
|---|---|
| Form Name | Form CMS-20027 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 20 |
| Avg. time to fill out | 4 min |
| Edition | 01/20 |
| Issuing agency | Centers for Medicare & Medicaid Services |
| Filing deadline | 120 days from the date of receipt of the initial claim determination |
| Where to send | The MAC that made the initial claim determination |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | CMS-20027, CMS20027, CMS 20027, Form CMS-20027, Medicare Redetermination Request Form |
| Official source | Form CMS-20027 (Rev 01/20), Centers for Medicare & Medicaid Services |
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