The Medicare appeals form you need depends on the level. Form CMS-20027 requests a first-level redetermination, CMS-20033 a second-level reconsideration, OMHA-100 an administrative law judge hearing and DAB-101 a Medicare Appeals Council review. Federal court review has no CMS form. Each level has its own deadline, counted from receipt of the previous decision.
The five Medicare appeal levels and the form for each
Original Medicare (Part A and Part B fee-for-service) has five appeal levels, and each one has a different reviewer and a different filing route. The CMS fee-for-service appeals overview lists them in order: redetermination, reconsideration, an Office of Medicare Hearings and Appeals (OMHA) decision, Medicare Appeals Council review and federal district court.
A party normally moves to the next level only after a decision at the one before. The table below gathers the reviewer, the form, the filing deadline and the usual decision time from the five CMS level pages and the federal regulations at 42 CFR part 405, subpart I. Every deadline is counted from the date the party receives the previous notice, and CMS presumes receipt five days after the date printed on the notice unless there is evidence otherwise.
| Level | Reviewer | Form | Filing deadline (source) | Decision time (source) |
|---|---|---|---|---|
| 1. Redetermination | Medicare Administrative Contractor (MAC) that made the initial determination | CMS-20027 or a written request | 120 days from receipt of the initial determination (42 CFR 405.942(a); CMS first-level page) | Generally 60 days from receipt of the request (CMS first-level page) |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | CMS-20033 or a written request | 180 days from receipt of the redetermination (42 CFR 405.962(a); CMS second-level page) | Generally 60 days, plus up to 14 days for each late evidence submission (CMS second-level page; 42 CFR 405.966(b)) |
| 3. Hearing | Administrative law judge or attorney adjudicator at OMHA | OMHA-100 or a written request | 60 days from receipt of the reconsideration (CMS third-level page) | Generally 90 days from receipt of the request (CMS third-level page) |
| 4. Council review | Medicare Appeals Council | DAB-101 or a written request | 60 days from receipt of the OMHA decision or dismissal (CMS fourth-level page) | 90 calendar days from receipt of the request (42 CFR 405.1100(c)) |
| 5. Judicial review | Federal district court | No CMS form | 60 days from receipt of the Council decision (CMS fifth-level page) | No time frame given on the CMS page |
The sources for each row are the CMS first-level redetermination page, the CMS second-level reconsideration page, the CMS third-level OMHA page, the CMS fourth-level Council page and the CMS fifth-level judicial review page.
Two levels also carry a minimum dollar amount in dispute, called the amount in controversy. The CMS first-level page says no minimum is needed for a redetermination. The CMS third-level page gives $200 for an OMHA hearing in calendar year 2026, and the fifth-level page gives $1,960 for federal court in calendar year 2026. Both figures are recalculated every year, so check the current page before you file.
A provider that wants someone else to handle the appeal uses a separate form. The CMS overview names Form CMS-1696, the Appointment of Representative form, for naming a representative.
The level 2 form gets its own field-by-field walkthrough in the guide to the fields on the Medicare reconsideration form. This post covers the level 1 form in detail and the route through all five levels.
Filling in the Medicare redetermination form as a provider
The Medicare redetermination form is Form CMS-20027, titled the Medicare Redetermination Request Form, 1st Level of Appeal. A provider, physician or supplier uses it to ask the MAC to look at a claim again. The form is one page, and the CMS-20027 PDF can be filled in on screen.
The top block identifies the claim. It asks for the beneficiary's name (first, middle, last), the Medicare number, the item or service being appealed, the date the service or item was received and the date of the initial determination notice. The form asks you to include a copy of that notice, which for a provider is the remittance advice (RA).
Three choices on the form are specific to providers:
- Overpayment box. The form asks "Does this appeal involve an overpayment?" with Yes and No, and marks the question as for providers and suppliers only. Tick Yes only when you are appealing a demand to repay money already paid.
- Evidence checkbox. You tick either "I have evidence to submit" or "I do not have evidence to submit". The form says you may attach the evidence, or a statement of what you will send and when, but all evidence must arrive before the redetermination is issued.
- Person appealing. You tick Beneficiary, Provider/Supplier or Representative, then give the name, street address, phone number and, optionally, an email address of the person filing.
The free-text box, "I do not agree with the determination decision on my claim because:", is where the argument goes. Name the denial reason from the RA and answer it directly. A second box, "Additional information Medicare should consider:", holds anything that does not fit the first.
The contractor name box is marked "not required" on CMS-20027. A separate box asks for your reason for late filing if you received the initial determination more than 120 days ago.
What makes a provider request valid
The Medicare Claims Processing Manual, chapter 29, section 310.1, says a completed CMS-20027 means all applicable spaces are filled out and all necessary attachments are included, and a provider request missing a required item is dismissed as incomplete. The required items, and the letter that can replace the form, are covered in which details Medicare contractors check in an appeal letter.
Corrections that are not appeals
Some denials should not be appealed at all. The CMS first-level page says MACs do not process claim corrections for minor errors and omissions through the appeals process. Chapter 29 adds that such a request is treated as a reopening and moved to the reopenings unit. A wrong digit in a date or a missing modifier usually belongs in a reopening, not on CMS-20027.
What are the Medicare appeal deadlines at each level?
Medicare appeal deadlines are 120 days for a redetermination, 180 days for a reconsideration, and 60 days for each of the last three levels. Each period starts when the party receives the previous decision, and receipt is presumed five days after the notice date, per 42 CFR 405.942(a)(1) and 405.962(a)(1).
The two early levels come straight from the regulations. Under 42 CFR 405.942, a redetermination must be filed within 120 calendar days from the date the party receives the initial determination notice. Under 42 CFR 405.962, a reconsideration must be filed within 180 calendar days of receiving the redetermination notice. The later three deadlines come from the CMS level pages: 60 days to request an OMHA hearing, 60 days to ask for Council review and 60 days to file in federal district court.
The filing date is the date the contractor receives the request, not the date you mail it. Chapter 29, section 310.2, says a deadline that ends on a Saturday, Sunday, legal holiday or other nonwork day rolls over to the first working day after it.
A worked deadline, with fictional dates
This example uses made-up dates. A fictional RA is dated March 2, 2026. Receipt is presumed five days later, on March 7. Counting 120 calendar days from March 7 lands on July 5, 2026, a Sunday. Under the rollover rule in section 310.2, the deadline becomes Monday, July 6, assuming no holiday applies. The MAC must receive the request by then.
Late filing and good cause
Both regulations let the contractor extend the deadline for good cause. Section 405.942(b) lists examples such as serious illness, records destroyed by fire, incorrect information from the contractor, and not receiving the notice. Chapter 29, section 240.3, is stricter for providers: it says MACs should not routinely find good cause for providers, and that a billing company's failure to file on time is not good cause.
These limits are appeal deadlines. The separate limit for submitting the original claim is a different rule, and this post does not cover it.
How does a Medicare Summary Notice appeal work?
A Medicare Summary Notice (MSN) appeal is how a beneficiary in Original Medicare starts a first-level appeal. The MSN is the statement Medicare mails to the beneficiary listing processed claims. The beneficiary marks the denied item on a copy of the MSN, explains the disagreement in writing and mails it to the address the MSN gives.
The Medicare.gov page on Original Medicare appeals sets out the steps. The beneficiary circles the item or service on a copy of the MSN, explains in writing why they disagree, adds their name, phone number and Medicare Number, includes any other supporting information and mails it to the Medicare claims office address on the last page of the MSN. The same page says the appeal must be filed by the date shown in the MSN, and offers CMS-20027 as an alternative to marking up the MSN.
The MSN appeal time frame matches the provider's: chapter 29, section 240, sets 120 days from receipt of the MSN or RA for a redetermination. Medicare.gov tells beneficiaries to file by the date printed in the MSN.
Providers often help with these appeals without filing them. Medicare.gov tells beneficiaries they can ask their provider for information that may help their case. Chapter 29, section 310.1, says a request filed by someone other than an appointed representative is honored when it shows the beneficiary knew of or approved it, for example when it comes with the beneficiary's MSN. If the provider wants to act for the beneficiary throughout, the appointment of representative route on Form CMS-1696 applies.
Beneficiary paperwork and the appeal file contain protected health information, so handling them follows the same privacy rules as any other record. The HIPAA and PHI category collects the posts on that.
Medicare appeals filed at the wrong level or contractor
A Medicare appeal sent to the wrong contractor, or labelled with the wrong level, is not always lost, but it can cost time against the deadline. Chapter 29 tells contractors to forward misfiled requests, and it treats a request for a level that has not happened yet as a request for the level that is due.
The manual covers three common mistakes.
- Skipping to level 2. If a MAC receives a "request for reconsideration" but has not yet done a redetermination, chapter 29, section 320.1, says it treats the request as a redetermination and does not forward it to the QIC.
- Sending level 2 to the MAC. If the MAC has already done the redetermination, it forwards the reconsideration request and the case file to the right QIC within 60 calendar days of receipt, per section 320.1.
- Filing with the wrong MAC. Section 310.1 says jurisdiction depends on where the service was provided for most Part B claims, where the beneficiary lives for Part B durable medical equipment claims, or the location of the A/B MAC for Part A provider claims. Misfiled requests are forwarded to the proper contractor within 60 calendar days.
Forwarding protects the request in some cases. Section 310.2 says that if a request was filed on time with another contractor or a federal agency and reached the right contractor late, the first filing date counts. Relying on that wastes weeks, though, and a forwarded case still has to be traced.
The safest habit is to copy the reviewer's name and address from the notice you are appealing. The CMS first-level page says MAC contact details are on the MSN and RA, and 42 CFR 405.964 says a reconsideration must be filed with the QIC named on the redetermination notice. The CMS second-level page lists the QIC fax numbers and portals by jurisdiction.
Medicare Advantage claims are a different system with different notices and reviewers. They are covered in the Medicare Advantage appeals process step by step, and none of the five levels above should be used for them.
Most appeals start from a code on a remittance. Schema Care reads EOB service lines and remark codes into fields with a confidence score each, and a person checks any field it is unsure of on the original page before it reaches your system, as the human review workflow shows. It does not file appeals.