Medicare redetermination request
Ask the Medicare contractor to review again a decision on your Original Medicare claim. This is the first appeal, called a redetermination.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. When your Medicare Summary Notice says Medicare will not pay for a service or item, and you have Original Medicare (Parts A and B). You must file within 120 calendar days of receiving the notice, and Medicare presumes you received it 5 days after the date on the notice. Check the date on your notice, which controls. Form CMS-20027, from the Centers for Medicare & Medicaid Services (CMS), is optional; a written request works too.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the Medicare contractor on your Medicare Summary Notice]
Re: Medicare redetermination request Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am asking for a redetermination, the first level of appeal, of a Medicare decision on my claim.
Name: [Your name] Medicare number: [Your Medicare number, as printed on your Medicare card] Claim number: [Claim or reference number] Date on the Medicare Summary Notice: [Date on the denial notice] Date of service: [Date of the care] Provider or supplier: [Doctor, hospital or pharmacy] Service or item: [The care or drug that was denied]
I disagree with the decision not to pay for this service or item. My reasons are: [Why you disagree with the decision]
I ask that you review the decision again and send me your decision in writing. I understand you must send a redetermination within 60 calendar days after you receive a timely request, and that I may send more evidence. Please tell me if you need anything else from me.
I understand a request is due within 120 calendar days of receiving the notice. I ask that this request be treated as filed on the day you receive it. I am enclosing the notice and the records that support my request. If you need more information from me or from my doctor, please contact me at the address in this letter before you decide.
Enclosures: 1. Copy of the Medicare Summary Notice, with the denied line marked 2. Form CMS-20027, if you use it (optional) 3. Letter from your doctor and medical records 4. Form CMS-1696, if someone is helping you
Sincerely, [Your name]
Before you send it
Send it to the contractor at the address on your Medicare Summary Notice, which explains how to ask for a redetermination. Use mail with tracking or the method the notice gives. The request counts as filed on the day the contractor receives it, so keep proof of the delivery date and a copy of everything.
What to enclose
- Copy of the Medicare Summary Notice, with the denied line marked
- Form CMS-20027, if you use it (optional)
- Letter from your doctor and medical records
- Form CMS-1696, if someone is helping you
What happens next
- Your deadline is 120 calendar days from receiving the notice. Medicare presumes receipt 5 days after the date on the notice. A late request can be accepted for good cause. Check the date on your notice, which controls. There is no minimum dollar amount.
- The contractor must send its decision within 60 calendar days after it receives a timely request. Each time you send more evidence after filing, the deadline can be extended by up to 14 calendar days.
- If the contractor says no, you can ask for a reconsideration by a Qualified Independent Contractor within 180 calendar days of receiving the redetermination notice. The form is CMS-20033.
- State Health Insurance Assistance Programs give free, one-on-one Medicare counseling and are not connected to any insurance company. Find yours at shiphelp.org or call 877-839-2675. You can also call 1-800-MEDICARE (1-800-633-4227).
- If you are writing for someone else, tick "I am writing for someone else". Original Medicare uses Form CMS-1696, Appointment of Representative. See also the letter "Name someone to act for you".