Printable blank Redetermination Request CMS-20027

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What is the blank Redetermination Request CMS-20027?

Fillable Redetermination Request CMS-20027 is a document created by the U.S Centers for Medicare & Medicaid Services for parties who desire to request a redetermination. 

What I need the blank Redetermination Request CMS-20027 for?

To request Medicare redetermination from the United States Department of Health & Human Services as the first level of appeal.

You will have to use the Fillable Redetermination Request CMS-20027 when:

  • You are not satisfied with the initial claim determination;
  • You wish to request a redetermination.

A redetermination request should be applied in written form. You can use the Fillable Redetermination Request CMS-20027 form in order to make a request.

How to fill out the Fillable Redetermination Request CMS-20027?

You have to begin filling CMS-20027 with writing down the name of the beneficiary. The medicare number should be specified. You should also mention the item or service you wish to appeal to.

The date the service or item was received should be also specified. Add the date of the initial determination notice (a copy is required with the request). If the notice was received more than 120 days ago, you have to write down the reasons for the late filling. You should also specify the reasons for your disagreement with the determination decision. If there is any additional information, you should write it down in the required field.  

The person appealing the document should be specified. The email of the person should also be submitted. Contact information and address should be also written down.

The printable blank Redetermination Request CMS-20027 consists of one page and 17 fields to fill out. In order to start filling out the form properly, it is necessary to state the beneficiary’s name and their Medicare number at the top of the form.

Fields 7 to 9 are used to bring up details on the appeal. There you will have to enter the name of the Medicare contractor, the reasons you disagree with the determination decision on your claim and bring up the additional information for Medicare to consider. Fields 10 to 17 are filled out with the information of the person appealing. It includes e-mail address, name, street address, telephone number and more.

Organizations that work with the Fillable Redetermination Request CMS-20027

  • U.S Centers for Medicare & Medicaid Services.
  • The United States Department of Health & Human Services.

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