How to Fill Out Form CMS-20027

Form CMS-20027 at a glance

What it is: Form CMS-20027 is the Medicare Redetermination Request Form, the 1st level of appeal.

Who signs: Mark the person appealing as Beneficiary, Provider/Supplier or Representative, and enter an email of the person appealing (optional).

A filled-in Form CMS-20027 example: a supplier appeals a denied claim

Form CMS-20027 example filled out, example: a supplier appeals a denied claim — Ana Sample, a supplier, appeals for Joe Sample on Form CMS-20027. She received the notice more than 120 days ago, so she gives a reason for the late filing. The picture shows the filled form, and none of its entries is real. The notice is dated 03/02/2026 and the appeal is dated 07/30/2026, 150 days later. Ana has evidence to submit and attaches it. The appeal does not involve an overpayment, so Ana marks No.

How to fill out Form CMS-20027, box by box

Beneficiary, item and dates

Enter the Beneficiary's name (First, Middle, Last), the Medicare number and the item or service you wish to appeal.

Enter the date the service or item was received and the date of the initial determination notice, both as mm/dd/yyyy, and 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.

Overpayment for providers and suppliers only

Does this appeal involve an overpayment? (for providers and suppliers only): mark Yes or No. The name of the Medicare contractor that made the determination is not required.

Why you do not agree and the evidence

Write why you do not agree with the determination decision on your claim, and add any additional information Medicare should consider.

If you have evidence to submit, attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it; all evidence must be received prior to the issuance of the redetermination. If you have no evidence, mark that you do not have evidence to submit.

Person appealing

Mark the person appealing as Beneficiary, Provider/Supplier or Representative, and enter an email of the person appealing (optional).

Enter the name of the person appealing (First, Middle, Last), the street address, the city, state and zip code, and the Telephone number of person appealing (include area code); the date of appeal (mm/dd/yyyy) is optional.

Sources

[1] Form CMS-20027 (2/14/2018), Medicare Redetermination Request Form, 1st Level of Appeal, Centers for Medicare & Medicaid Services (the Official source link on this page).

Form CMS-20027 PDF Details

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

CMS-20027: Medicare Redetermination Request Form