Medicare Request Form PDF Details

Navigating through the Medicare system can be challenging, especially when disputes arise regarding coverage decisions. The Medicare Redetermination Request Form, also known as Form CMS-20027, serves as a critical tool for individuals seeking to challenge these decisions. Managed by the Department of Health and Human Services and overseen by the Centers for Medicare & Medicaid Services, this form marks the first level of appeal in the Medicare appeals process. It is designed for beneficiaries, providers, or suppliers who disagree with an initial determination regarding Medicare coverage or payment. The form requires detailed information, including the beneficiary's name, Medicare number, the service or item being appealed, and the date the service was received. An essential part of this process involves submitting evidence to support the appeal, which can drastically influence the outcome. Additionally, it outlines the necessity of including the date of the initial determination notice and underscores the importance of filing the appeal within 120 days of receiving this notice to avoid the need for an explanation for any delay. This form not only facilitates a structured appeal process but also upholds the individual's right to challenge decisions made by Medicare contractors. The provided Privacy Act Statement reassures applicants about the confidentiality and intended use of their information, emphasizing that submission is voluntary but crucial for the appeal's consideration. As such, the Medicare Redetermination Request Form plays a pivotal role in ensuring that disputes regarding Medicare decisions are addressed promptly and effectively.

QuestionAnswer
Form NameMedicare Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshow to form cms 20027, cms 20027 form, medicare form cms 20027, forms for medicare

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB Exempt

MEDICARE REDETERMINATION REQUEST FORM — 1st LEVEL OF APPEAL

Beneficiary’s name (First, Middle, Last)

Medicare number

Item or service you wish to appeal

 

 

Date the service or item was received (mm/dd/yyyy)

Date of the initial determination notice (mm/dd/yyyy) (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:

Name of the Medicare contractor that made the determination (not required)

Does this appeal involve an overpayment?

 

(for providers and suppliers only)

 

Yes

No

 

 

 

I do not agree with the determination decision on my claim because:

 

 

Additional information Medicare should consider:

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.

Person appealing: Beneficiary

Provider/Supplier

Representative

Email of person appealing (optional)

Name of person appealing (First, Middle, Last)

Street address of person appealing

City

State

Zip code

Telephone number of person appealing (include area code)

Date of appeal (mm/dd/yyyy) (optional)

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 & 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 83 Fed. Reg. 6591 (2/14/2018) or at https://www.hhs.gov/foia/privacy/sorns/cms-sorns.html

Form CMS-20027 (01/20)

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Zip code, Provider Supplier, and Email of person appealing optional inside cms20027

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