The following information MUST be included with your request for all appeal levels.

• Beneficiary name
• Medicare Health Insurance Claim (HIC) Number
• Specific service(s) and/or item(s) for which the redetermination is being requested;
• Specific date(s) of the service; and
• Name and signature of the party or the representative of the party.

First Level – Redetermination (issued on or after May 1, 2005)

The first level of appeal is carried out by the Fiscal Intermediary/Carrier
Time limit to initiate – 120 days from the date of the initial determination
Time limit to complete the review – 60 days
Amount in controversy – No minimum amount

Send the completed form CMS 20027 - Medicare Redetermination Request to:
National Government Services, Inc.
PO Box 4711
Syracuse, NY 13221-4711

Second Level – Reconsideration

The second level of appeal is carried out by the Qualified Independent Contractor (QIC)
Time limit to initiate – 180 days from the date of the Redetermination decision
Time limit to complete the review – 60 days
Amount in controversy – No minimum amount

Send the completed CMS 20033 - Medicare Reconsideration Request form to:
MAXIMUS Federal Services
QIC Part A East Project
1040 First Avenue, Suite 400
King of Prussia, PA 19406

Third Level – Administrative Law Judge (ALJ) Hearing

The third level of appeal is an ALJ Hearing
Time limit to initiate – 60 days from the date of the Qualified Independent Contractor decision
Time limit to complete the review – 90 days
Amount in controversy – $120

Send the completed CMS 20034A/B - Request for Medicare Hearing by an ALJ form to:
HHS OMHA Field Office
BP Tower & Garage
200 Public Square, Suite 1300
Cleveland, Ohio 44114-2316

NOTE: Send to the above OMHA (Office of Medicare Hearings and Appeals) Field Office address for services performed in CT, DE, MA, NY

If place of service is in another state, refer to OMHA Field Office addresses

Fourth Level – Departmental Appeals Board (DAB)

The fourth level of appeal is carried out by the DAB
Time limit to initiate – 60 days from the Administrative Law Judge decision
Time limit to complete the review – 90 days
Amount in controversy – No minimum amount

Send request for a DAB review to:
Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, SW
Cohen Building, Room G-644
Washington, DC 20201

Fifth Level – Federal Court Review

The fifth level of appeal is carried out by the Federal District Court
Time limit to initiate – 60 days from the Medicare Appeals Council decision
Amount in controversy – $1180

Send request for a judicial review to:
Department of Health and Human Services
General Counsel
200 Independence Avenue, SW
Washington, DC 20201

Page Last Modified: 02/12/08