Form Cms 20033 PDF Details

Navigating the United States healthcare system, particularly with respect to Medicare, can often seem like a daunting task, replete with numerous forms and procedures that must be meticulously followed. Among these, the CMS 20033 form represents a crucial step for individuals seeking to challenge a decision made by Medicare regarding their claims. This form is officially titled the "Medicare Reconsideration Request Form" and serves as the second level of appeal in the Medicare appeals process. It allows beneficiaries, providers, or suppliers to formally dispute a previous Medicare decision concerning coverage or payment for a service or item. The form requires detailed information, including the beneficiary’s name, Medicare number, and specifics about the disputed service or item, such as what it was and when it was received. Additionally, it requests a copy of the initial redetermination notice — a document critical to proceeding with the appeal if the decision was made more than 180 days prior to filing the appeal, the filer must provide a reason for the delay. Importantly, the form also prompts an explanation as to why the initial determination was incorrect and any additional evidence or documents to support the appeal. It underscores the significance of providing a comprehensive rationale and supporting evidence to counter the initial determination made by Medicare. This appeal process underscores the Centers for Medicare & Medicaid Services' commitment to ensuring that those covered by Medicare have the right and ability to question decisions that directly impact their care and financial responsibilities.

QuestionAnswer
Form NameForm Cms 20033
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfillable reconsideration form cms 20033, 1869, disclosures, CMS-20033

Form Preview Example

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?

Yes

No

(for providers and suppliers only)

 

 

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. 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-20033 (12/10)

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Filling in part 1 of overpayment

2. Once the last part is done, go on to enter the relevant details in these: I do not agree with the, Additional information Medicare, I have evidence to submit Please, I do not have evidence to submit, Person appealing Beneficiary, ProviderSupplier, Representative, Name address and telephone number, Signature of person appealing, and Date signed.

overpayment conclusion process shown (part 2)

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Filling in part 3 in overpayment

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