CMS-20033 Medicare Reconsideration Request form – 2nd level of appeal

Medicare Form Summary

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.

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