The Medicare reconsideration form is Form CMS-20033, the request for a second-level appeal after a Medicare contractor upholds a denial at redetermination. You send it to the Qualified Independent Contractor named on the redetermination notice within 180 days of receiving that notice, with a copy of the notice and every piece of evidence you plan to rely on.
Who reviews a Medicare reconsideration request?
A Medicare reconsideration request is reviewed by a Qualified Independent Contractor (QIC), a company under contract with CMS that did not make the earlier decisions. The CMS second-level appeal page describes a reconsideration as "an independent review of the administrative record", including the first-level redetermination.
The QIC is not the Medicare Administrative Contractor (MAC) that denied the claim and decided the redetermination. Several QICs split the work by claim type and region. The CMS page lists them by jurisdiction: Part A East, Part A West, Part B North, Part B South and durable medical equipment (DME), each with its own fax number or appeals portal. The Medicare Claims Processing Manual, chapter 29, section 320.1, says Part A QIC jurisdiction follows the state where the service was rendered, while DME and Part B jurisdiction follow the state where the beneficiary lives.
You do not have to work that out yourself. Under 42 CFR 405.964, the request must be filed with the QIC indicated on the notice of redetermination. Copy the name and address from that notice.
The CMS page says the QIC generally sends its decision within 60 days of receiving the request. If it cannot, it must tell the parties and explain the right to escalate the appeal to the Office of Medicare Hearings and Appeals. Where reconsideration sits among the other four levels, with every deadline, is laid out in the five Medicare appeal levels and the form for each.
Fields on the Medicare reconsideration form
The fields on the Medicare reconsideration form identify the beneficiary, the service, the earlier decision and the person appealing. The CMS-20033 PDF, titled the Medicare Reconsideration Request Form, 2nd Level of Appeal, is one page. The table below walks through it with a fictional completed example.
Every value in the example column is made up. The patient, the practice, the Medicare number and the dates do not belong to anyone.
| Field on CMS-20033 | What goes in it | Fictional example |
|---|---|---|
| Beneficiary's name (First, Middle, Last) | The name exactly as on the Medicare card | Rosa M. Example |
| Medicare number | The beneficiary's Medicare number from the notice | 1EG4TE5MK73 (example) |
| Item or service you wish to appeal | The service and its procedure code | Physical therapy, CPT 97110, 4 units |
| Date the service or item was received | The date of service, mm/dd/yyyy | 04/14/2026 |
| Date of the redetermination notice | The date printed on the MAC's decision; attach a copy | 06/22/2026 |
| Reason for late filing | Only if the notice arrived more than 180 days ago | Left blank |
| Name of the Medicare contractor that made the redetermination | The MAC's name; not required if the notice is attached | Sample MAC Region 9 (example) |
| Does this appeal involve an overpayment? | Providers and suppliers only | No |
| I do not agree with the redetermination decision on my claim because: | A direct answer to the reason stated in the redetermination | The redetermination said the plan of care was unsigned. The signed plan of care dated 04/10/2026 is attached. |
| Additional information Medicare should consider: | Anything else that bears on the issue | Progress note for 04/14/2026 attached, showing minutes and exercises. |
| I have evidence to submit / I do not have evidence to submit | Tick one | I have evidence to submit |
| Person appealing | Beneficiary, Provider/Supplier or Representative | Provider/Supplier |
| Name, address, phone and email of person appealing | Contact details for whoever files | Lakeview Example Therapy, 100 Sample Road, Springfield (example) |
| Date of appeal | Optional | 07/01/2026 |
Three fields carry most of the weight. The redetermination notice date starts the clock. The "I do not agree" box is the argument. The evidence checkbox tells the QIC whether more paper is coming.
The form is optional. The CMS page and 42 CFR 405.964(b) accept a written request instead, if it contains the beneficiary's name, the Medicare number, the specific services and dates, the name of the party or representative, and the name of the contractor that made the redetermination. The CMS page adds any documentation the redetermination notice said was missing. A letter built around those elements is shown in the Medicare appeal letter sample.
What evidence belongs with a Medicare reconsideration?
Evidence for a Medicare reconsideration is everything you want any later reviewer to see. That includes the records that answer the denial reason and any document the redetermination notice listed as missing. Reconsideration is the last easy chance to add it, because evidence held back without good cause can be excluded at later levels.
The rule is in 42 CFR 405.966. It says a party should present evidence and allegations of fact or law related to the issue in dispute, including any missing documentation identified in the notice of redetermination. Absent good cause, failing to submit that evidence before the reconsideration is issued generally rules it out of later consideration. The CMS page puts it plainly: documentation not submitted at this level may be excluded at subsequent levels unless good cause is shown.
Late evidence also slows the decision. Section 405.966(b) says each extra submission after filing extends the QIC's 60-day time frame by up to 14 calendar days, unless the QIC asked for that documentation itself and the redetermination notice had not already asked for it. The form's own instruction agrees: you may send evidence later, but it must arrive before the reconsideration is issued.
In practice, start with the redetermination notice and list every reason it gives. For each reason, attach the record that answers it, such as a signed order, a plan of care, a progress note or a corrected document. Requesting those records from another provider takes time, and the records retrieval and review category covers that work.
Medicare reconsideration requests past the 180-day deadline
A Medicare reconsideration request filed more than 180 days after you received the redetermination notice is late, and the QIC can dismiss it. Under 42 CFR 405.962(b), the QIC may extend the deadline only if you show good cause, in writing, filed together with the reconsideration request itself.
The 180-day limit is in 42 CFR 405.962(a). Receipt is presumed five calendar days after the notice date unless there is evidence otherwise, and the request counts as filed when the QIC receives it. With the fictional notice dated June 22, 2026 from the table above, receipt is presumed June 27, and 180 days later is December 24, 2026.
CMS-20033 has a box for the late-filing reason: "If you received your redetermination notice more than 180 days ago, include your reason for the late filing." Section 405.962(b)(3) says the QIC applies the good cause standards in 405.942(b)(2) and (b)(3), which look at what prevented timely filing and whether the contractor's own actions misled the party.
Providers should expect a narrow reading. Chapter 29, section 240.3, says contractors should not routinely find good cause for providers, physicians or suppliers. It names incorrect information from official sources and unavoidable events such as floods and fires as examples that may qualify. It also says a billing company's failure to file on time is not good cause.
Misfiling can also eat into the period, although chapter 29, section 320.2, treats a request mailed in good faith to CMS or another government agency within the limit as timely even if it reaches the QIC late. How misfiled requests are forwarded is covered in Medicare appeals filed at the wrong level or contractor.
None of this applies to Medicare Advantage plans, which run their own reconsideration step. That route is covered in the post on Medicare Advantage appeals and grievances.
Before any of this, someone has to read the denial on the remittance correctly. Schema Care turns EOB lines and remark codes into structured fields and routes the ones under your confidence threshold to a reviewer, which the fictional EOB demo shows. Filing the appeal stays with your team.