Get Help Submitting an 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 appeal request form, the Complete the Part A Redetermination Request Form Level 1:

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.

Helpful Tips

• 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 review the What Documents are Needed? page.

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.

Appealing a Third Party Liability Demand Claim

An appeal of a TPL demand claim may be completed by submitting a hard-copy request. The request for a redetermination can be sent on the Home Health Third Party Liability Demand Bill Redetermination Request Form or in writing.

If you prefer to send a written request in the form of a letter, it should be submitted on company letterhead and include all of the following information:

• Provider name and address (if not included on letterhead)
• Beneficiary’s name
• Beneficiary’s Medicare number
• Claim dates of service
• Item(s)/Service(s) you wish to appeal
• Signature
• Indicate that the appeal is for a TPL demand claim

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