Request an Original Medicare claim redetermination

Your next steps

1. Read the Medicare Summary Notice to identify the denied item, appeal deadline and Medicare Administrative Contractor.
2. Use the redetermination form or a written request with the beneficiary, claim, service dates and reason for disagreement.
3. Send it to the contractor address on the MSN and keep a copy and delivery proof.
4. Add relevant provider records; use appointment-of-representative paperwork if another person acts for you.

What forms or applications do I need?

• Medicare Redetermination Request Form ↗ (optional) — First-level Original Medicare claim appeal. Source page captured; verify current edition and instructions.
• Appointment of Representative ↗ (conditional) — Authorize a representative when required. Source page captured; verify current edition and instructions.

How much time do I have, and when must I file?

Where and how do I file?

Receiving office: Medicare Administrative Contractor named on the MSN.

Submission method: Mail or other submission channel expressly provided by that contractor.

Jurisdiction and venue: Federal claim administrator assigned to the claim.

Craighead County check: Residents of every county follow their MSN contractor instructions; neither a county court nor Medicaid eligibility office handles this appeal.

Use the named agency, federal office or provider’s current instructions. County court filing contacts do not replace this submission route.

Before you submit: Verify signatures, attachments, current form edition, fees or fee-waiver process, service requirements, and whether the office must receive or accept the filing by the deadline. Keep the accepted copy or receipt and follow up on rejected submissions. A referral or phone call does not extend a separate deadline.

Limits: This profile does not supply a numeric period not captured from the current primary page.