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Medicare Appeals Forms
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 will need Adobe Reader software to view the files.
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You have the right to appeal any decision about your Medicare services. This is true whether you are 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 have been given, or if you are 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.
Medicare Appeals Frequently Asked Questions
| Medicare Appeals Forms |
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| Form Number |
Form Information |
| CMS-10095 (NOMNC) |
Notice of Medicare Non-Coverage
This notice explains that the Medicare Health Plan and/or provider has determined that Medicare probably will not pay for a specific service after a specific effective date.
View Form in Adobe PDF (Size: 98 KB)
View Instructions in Adobe PDF (Size: 94 KB) |
| CMS-10095 (DENC) |
Detailed Explaination of Non-coverage
This notice gives a detailed explanation of why the Medicare Health Plan and/or provider has determined that Medicare coverage for a specific service should end.
View Form in Adobe PDF (Size: 15 KB)
View Instructions in Adobe PDF (Size: 16 KB) |
| CMS-1696 |
Appointment of Representative
This form should be used to appoint a representative.
View Form in Adobe PDF (Size: 120 KB)
View Spanish Form in Adobe PDF (Size: 145 KB) |
| CMS-20031 |
Transfer Of Appeal Rights
This form allows you to transfer your appeal rights to your health care provider for an item or service.
View Form in Adobe PDF (Size: 36 KB) |
| CMS-20027 |
Medicare Redetermination Request Form
This form should be used to request a redetermination. This needs to be filed 120 days from the date of receipt of the initial claim determination (normally the date of the MSN). There is no minimum amount required to file a redetermination.
View Form in Adobe PDF (Size: 50 KB) |
| CMS-20033 |
Medicare Reconsideration Request Form
This form should be used to request a reconsideration. This needs to be filed 180 days from the receipt date of the determination decision. There is no minimum required to file a reconsideration.
View Form in Adobe PDF (Size: 48 KB) |
| CMS-20034A/B |
Request for Medicare Hearing by an Administrative Law Judge
This form should be used to request a hearing by an Administrative Law Judge (ALJ) about a reconsideration determination issued by a Qualified Independent Contractor (QIC). This needs to be requested 60 days from the receipt date of the reconsideration decision.
If your reconsideration determination was issued by a Qualified Independent Contractor (QIC) please use form CMS-20034A/B
View Form in Adobe PDF (Size: 85 KB).
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| CMS-5011A/B |
Request for Part B Medicare Hearing by an Administrative Law Judge
This form should be used to request a hearing by an Administrative Law Judge (ALJ) about a determination issued by a Part A Medicare Administrative Contractor (MAC), Part B MAC, or Quality Improvement Organization (QIO). This needs to be requested 60 days from the receipt date of the reconsideration decision.
View English Form in Adobe PDF (Size: 12 KB)
View Spanish Form in Adobe PDF (Size: 12 KB)
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Medicare Appeals Information
A list of all CMS forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp.
Page Last Updated: October 2, 2008
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