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  • Cgs Redetermination Request Form

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RECONSIDERATION REQUEST FORM Redetermination Number Contractor 18003 CGS DME MAC - C DIRECTIONS If you wish to appeal this decision please fill out the required information below and mail this form to the address shown below. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Pro....

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A Certificate of Medical Necessity (CMN) or a Information Form (DIF) is a form required to help document the medical necessity and other coverage criteria for selected durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items.

A redetermination is the first level of the appeals process and is an independent re-examination of an initial claim determination. A claim must be appealed within 120 days from the date of receipt of the initial Medicare Summary Notice (MSN), Remittance Advice (RA) or Overpayment Demand Letter.

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

Fill out the form CMS-20027 (available in Downloads below). Make a written request containing all of the following information: Beneficiary name. Medicare number. Specific service(s) and/or item(s) for which a redetermination is being requested. Specific date(s) of service.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232