Medicare Provider Complaint and Appeal Form

To submit this form, please mail it to Medicare Provider Appeals at PO Box 14835, Lexington, KY 40512. You can also fax the completed form to 1-860-900-7995. Ensure all required fields are filled in and relevant documents are attached to avoid processing delays. For further assistance, reach out to Medicare's customer support.

For 2024 and 2025, keep an eye on the Medicare guidelines that may affect the appeals process. Ensure your submissions comply with any updated regulations. Be aware of deadlines outlined in your denial notifications to maintain your appeal rights.

The purpose of this form is to provide a clear process for Medicare members to appeal decisions made by the Medicare program. It ensures that members can communicate their concerns effectively and have their claims re-evaluated. By utilizing this form, members give themselves a structured opportunity to present their case and receive a fair review.

• 1. Today's Date: The date you are filling out the form.
• 2. Member's ID Number: The unique identification number assigned to the member.
• 3. Plan Type: Indicates the type of Medicare plan the member is enrolled in.
• 4. Member's Group Number: An optional group identifier for the member.
• 5. Member's First Name: The first name of the member submitting the appeal.
• 6. Member's Last Name: The last name of the member.
• 7. Member's Birthdate: The member's date of birth in MM/DD/YYYY format.
• 8. Provider Name: The name of the healthcare provider involved in the claim.
• 9. TIN/NPI: Tax Identification Number or National Provider Identifier of the provider.
• 10. Provider Group: The healthcare provider's group name, if applicable.
• 11. Contact Name and Title: The name and title of the contact person for the appeal.
• 12. Contact Address: The address where resolution should be sent.
• 13. Contact Phone: The phone number for the contact person.
• 14. Contact Fax: The fax number for sending documents.
• 15. Contact Email Address: The email address for the contact person.
• 16. Claim ID Number(s): The ID number(s) of the claim(s) being disputed.
• 17. Reference Number/Authorization Number: The authorization number if applicable.
• 18. Service Date(s): The date(s) of service related to the claim.
• 19. Initial Denial Notification Date(s): The date(s) when the member was informed of the denial.
• 20. Reconsideration Denial Notification Date(s): The date(s) when the reconsideration of the claim was denied.
• 21. CPT/HCPC/Service Being Disputed: The codes for the services being appealed.
• 22. Explanation of Your Request: A detailed description of the reason for the appeal.

If the form is not submitted correctly, your appeal may be delayed or denied. It is essential to ensure all required fields are filled out accurately and completely. Missing information can lead to complications in processing your request.

• Incomplete Information: Failure to provide required details can result in delays.
• Incorrect Submission Method: Submissions sent to the wrong address will not be processed.
• Missing Supporting Documents: Not attaching relevant records may weaken your appeal.
• Late Submission: Submitting after the deadline can forfeit your right to appeal.
• Poorly Written Explanation: A vague or unclear explanation may affect the review outcome.

• 1. Claim Denial Appeal: To dispute a denial of a claim for medical services.
• 2. Overbilling Issues: To contest charges that exceed agreed-upon costs.
• 3. Service Disputes: To challenge decisions regarding whether a service is covered.
• 4. Insurance Coverage Changes: To address any discrepancies in coverage.
• 5. Timeliness of Care: To appeal regarding delays or denials in receiving necessary care.