You’ll need the CMS-20033 form if Medicare denies your first appeal.
What you’ll need:
• Name and Medicare number
• Service or item you wish to appeal
• Date the service or item was received
• A clear explanation of why you disagree with the redetermination decision
• Any evidence that supports your claim, including information provided by your doctor
Other important information:
• Medicare’s redetermination decision will be communicated through a Medicare Redetermination Notice (MRN), a Medicare Summary Notice (MSN), or a Remittance Advice (RA).
• This form must be filed within 180 days of receiving your Redetermination Request denial.