Official forms

• Appointment of Representative (Form CMS-1696) (opens the official site in a new tab)

  You need it when you want a family member, friend, advocate, attorney or doctor to act for you in a Medicare appeal.

  From Centers for Medicare & Medicaid Services

• Ask EBSA: request help from a benefits advisor (opens the official site in a new tab)

  You need it when an employer health plan will not follow its claims and appeal rules, or you want help with a self-funded plan that your state insurance department cannot help with.

  From United States Department of Labor, Employee Benefits Security Administration

• California Independent Medical Review request (opens the official site in a new tab)

  You need it to ask for independent review of a denial for medical necessity or experimental treatment, within 6 months after your plan's written response to your appeal.

  From California Department of Managed Health Care and California Department of Insurance

• Connecticut external review application (opens the official site in a new tab)

  You need it to ask for independent review once your internal appeals are exhausted, within 120 days after the insurer's written notice, with no filing fee.

  From Connecticut Insurance Department

• Dispute a medical bill (uninsured and self-pay patients) (opens the official site in a new tab)

  You need it when you have no insurance or chose not to use it and your bill is at least $400 more than your good faith estimate, and you must start within 120 calendar days of the initial bill.

  From Centers for Medicare & Medicaid Services

• Federal external review request (administered by the Department of Health and Human Services) (opens the official site in a new tab)

  You need it when your final denial letter says your plan uses the federal process for independent review, and you must ask within four months of receiving that letter.

  From Department of Health and Human Services

• Illinois external review request (opens the official site in a new tab)

  You need it to ask for independent review after your insurer's final denial, within 4 months of receiving the final denial letter.

  From Illinois Department of Insurance

• Important Message from Medicare (Form CMS-10065) (opens the official site in a new tab)

  This is the notice a hospital must give you near admission and again before discharge, and it tells you how to ask for a fast review of a discharge by the Quality Improvement Organization.

  From Centers for Medicare & Medicaid Services

• Marketplace appeal request (opens the official site in a new tab)

  You need it when the Marketplace itself made a decision about your eligibility or tax credit, within 90 days of the eligibility notice, and not when a health plan denied a claim.

  From Health Insurance Marketplace (HealthCare.gov)

• Massachusetts external review request (opens the official site in a new tab)

  You need it to ask for independent review of your insurer's final denial, within 4 months of receiving the final adverse determination letter.

  From Office of Patient Protection (Massachusetts Health Policy Commission)

• Medicare Advantage plan appeal (reconsideration) (opens the official site in a new tab)

  You need this page when a Medicare Advantage plan has denied a service or payment and you want the plan to reconsider, within 65 calendar days of the date on the denial notice.

  From Centers for Medicare & Medicaid Services

• Medicare Part D plan appeal (redetermination) (opens the official site in a new tab)

  You need this page when your drug plan has denied a drug and you want the plan to decide again, within 65 calendar days of the date on the denial notice.

  From Centers for Medicare & Medicaid Services

• Medicare reconsideration request (Form CMS-20033) (opens the official site in a new tab)

  You need it for the second level of an Original Medicare appeal, within 180 calendar days of receiving the redetermination notice.

  From Centers for Medicare & Medicaid Services

• Medicare redetermination request (Form CMS-20027) (opens the official site in a new tab)

  You need it to ask the Medicare contractor to look again at a denied Original Medicare claim, within 120 calendar days of receiving the decision, and a written request following your Medicare Summary Notice also works.

  From Centers for Medicare & Medicaid Services

• Minnesota external review request (opens the official site in a new tab)

  You need it to ask for independent review of a denial, within 6 months of the date of the adverse determination you are appealing.

  From Minnesota Department of Commerce and Minnesota Department of Health

• No Surprises Act complaint (opens the official site in a new tab)

  You need it when a plan, provider or facility may have broken the surprise billing rules, and you can also call the No Surprises Help Desk at 1-800-985-3059.

  From Centers for Medicare & Medicaid Services

• Notice of Denial of Medical Coverage or Payment (Form CMS-10003) (opens the official site in a new tab)

  This is the written denial a Medicare Advantage plan must send you, and it is the notice to recognise before you file a plan appeal.

  From Centers for Medicare & Medicaid Services

• Notice of Medicare Non-Coverage (Form CMS-10123) (opens the official site in a new tab)

  This is the notice a skilled nursing, home health, rehabilitation facility or hospice provider must give you at least 2 days before covered services end, and your fast appeal is due by noon of the next calendar day.

  From Centers for Medicare & Medicaid Services

• Office of Personnel Management review of a disputed federal employee plan claim (opens the official site in a new tab)

  You need it after your Federal Employees Health Benefits carrier upholds a denial, and you generally have 90 days from the carrier's letter to ask the Office of Personnel Management to review.

  From United States Office of Personnel Management

• Pennsylvania independent external review request (opens the official site in a new tab)

  You need it to ask for independent review of a denied treatment, medication or service, within 4 months of the final adverse benefit determination letter.

  From Pennsylvania Insurance Department

• Request for a Medicare hearing by an Administrative Law Judge (Form OMHA-100) (opens the official site in a new tab)

  You need it for the third level of a Medicare appeal, within 60 calendar days of receiving the reconsideration decision, if the amount in dispute meets the threshold ($200 in 2026).

  From Office of Medicare Hearings and Appeals (Department of Health and Human Services)

• Request for Medicare Appeals Council review (Form DAB-101) (opens the official site in a new tab)

  You need it for the fourth level of a Medicare appeal, within 60 calendar days of receiving the judge's decision.

  From Departmental Appeals Board (Department of Health and Human Services)

• TRICARE appeals (opens the official site in a new tab)

  You need it when TRICARE denies a claim or authorization, and your written request for reconsideration must be postmarked within 90 days of the date on the Explanation of Benefits or decision.

  From TRICARE (Defense Health Agency)

• Veterans Affairs clinical appeal (opens the official site in a new tab)

  You need it when you disagree with a Veterans Affairs care team's medical treatment decision, and you send it in writing to the patient advocate at your Veterans Affairs medical facility.

  From Department of Veterans Affairs

• Veterans Affairs Higher-Level Review (VA Form 20-0996) (opens the official site in a new tab)

  You need it to ask for a new look, without new evidence, at a Veterans Affairs health care benefit decision such as a community care claim, within one year of the decision notice.

  From Department of Veterans Affairs

• Virginia external review request (opens the official site in a new tab)

  You need it to ask for independent review, and the Bureau must receive a complete request within 120 days after you received notice of your right to external review.

  From Virginia State Corporation Commission, Bureau of Insurance

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