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'll need Adobe Reader software to view the files.
You've the right to appeal any decision about your Medicare services. This is true whether you're 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've been given, or if you're 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.
| Form number | Form name | Form description | Link(s) to form |
|---|---|---|---|
| CMS-1696 | "Appointment of Representative" | You should use this form if you want to name someone to represent you to help appeal your claim. | Appointment of Representative form Nombramiento de representante (Appointment of Representative form) |
| CMS-20031 | "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. | Transfer of Appeal Rights form |
| CMS-20027 | "Medicare Redetermination Request" | 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. | Redetermination Request form |
| CMS-20033 | "Medicare Reconsideration Request" | Use this form if you're 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. | Medicare Reconsideration Request form |
| CMS-20034A/B | "Request for Medicare Hearing by an Administrative Law Judge" | Use this form if you're 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. To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2012, the required amount is $130. The "Medicare Reconsideration Notice" will include a statement that tells you if your case meets the minimum dollar amount. However, it's up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.
| Request for Hearing by an Administrative Law Judge form |