Medicare Appeals Forms
You can view and print appeal forms online by accessing the links below. All of the forms are Adobe Acrobat version 7.0.5 accessible. You will need Adobe Reader software to view the files.
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You have the right to appeal any decision about your Medicare services. This is true whether you are in the Original Medicare Plan, a Medicare managed care plan, or a Medicare prescription drug plan. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal. You should review the Medicare Appeals Information before downloading the forms below.
Medicare Appeals Frequently Asked Questions
|Medicare Appeals Forms|
||Appointment of Representative
You should use this form if you want to name someone to represent you to help appeal your claim.
View Form in Adobe PDF (Size: 120 KB)
View Spanish Form in Adobe PDF (Size: 145 KB)
||Transfer of Appeal Rights
Use this form to transfer your appeal rights to your provider or supplier. Your provider or supplier may not have the right to appeal your claim in some situations.
View Form in Adobe PDF (Size: 36 KB)
||Medicare Redetermination Request Form
If you don't agree with the initial claim decision by Medicare, you should use this form to appeal your claim. This is called a redetermination and is the first level of the appeals process. This is done by the Medicare Contractor who processed your claim. Any dollar amount can be appealed at this level, but it needs to be submitted within 120 days from the date you received the initial claim decision. This is normally the date shown on your Medicare Summary Notice (MSN). To file an appeal, you can also follow the instructions on your MSN by signing and returning the notice to the Medicare Contractor who processed your claim.
View Form in Adobe PDF (Size: 50 KB)
||Medicare Reconsideration Request Form
Use this form if you are dissatisfied with the redetermination decision made during your first level of appeal. This form is used for the second level of appeals for your claim. This request is called a reconsideration and is done by a Qualified Independent Contractor (QIC). Any dollar amount can be appealed at this level, but it needs to be submitted within 180 days from the date of your redetermination decision.
View Form in Adobe PDF (Size: 48 KB)
Request for Medicare Hearing by an Administrative Law Judge
Use this form is you are dissatisfied with the QIC reconsideration decision made during your second level of appeal. This form is used to request a hearing by an Administrative Law Judge (ALJ). This is the third level of appeals. This request needs to be submitted within 60 days from the date of your reconsideration decision. The claim(s) you are appealing must be more than $120.
View Form in Adobe PDF (Size: 85 KB).
Medicare Appeals Information
Page Last Updated: October 8, 2008