Get Help Submitting a Appeal Hard Copy

All levels of appeals may be submitted by mail. The only types of appeals submitted to National Government Services are reopening and redetermination requests. For information on other types of appeals, check the Levels of Appeals and Time Limits for Filing page.

Step 1: Complete the Appeals Request Form

Download and complete the Part B Appeals Request Form: Redetermination: First Level of Appeal form:

1. Complete the form by typing the appropriate information into the form. If you cannot type the request, please make sure your handwriting is legible.
2. Complete all areas of the form. An incomplete form will not be accepted and your request will be dismissed.
3. Print the completed form and sign it.

Helpful Tips:

• The beneficiary name, Medicare Beneficiary Identifier, dates of service, item/service at issue and the signature of the requestor are required for any appeal to be processed.
• Please make sure all items are completed. If there is not enough room on the form, please include an attachment that details the required information (i.e., include your remittance and placing a star next to all claims to be reviewed).
• If there is insufficient information with your appeal request, it may be dismissed.
• If you are submitting your appeal past the time limit, please include an explanation for the delayed request.

Step 2: Attach Supporting Documentation

Print and include with your appeal any medical documentation that supports your request. The medical documentation must be signed and dated by the physician. For help in determining what documentation should be submitted, please visit What Documents are Needed?

Step 3: Mail Appeal Request Form and Documentation

Send your prepared appeals request form and all supporting documentation to the appropriate National Government Services for your jurisdiction.

Please share your thoughts about your experience with our redetermination process.