Second Level of Appeal: Reconsideration Request Form

There are five levels within the Medicare appeals process that a provider or beneficiary can use when they do not agree with a claim determination. The first level is a Redetermination and that is processed  by the Medicare Administrative Contractor (MAC) Appeals staff. Appeals staff are not involved in the initial claim determination. Once a Redetermination has been filed and processed, an appellant (if dissatisfied with the result of the redetermination) can progress to the second level of appeal, known as a Reconsideration. Reconsiderations are conducted by the Qualified Independent Contractor, or QIC, which is a separate entity from Palmetto GBA.

Second level appeal requests must be submitted in writing by using the
CMS 20033a form (PDF, 180 KB), which is on the CMS website. Reconsiderations must be filed to the QIC within 180 days of receipt of the Medicare Redetermination Notice letter. There is no minimum amount in controversy to be met. The QIC then has 14 days to acknowledge a reconsideration request. Reconsiderations are to be processed within 60 days by the QIC.

It is not necessary to send any documentation that was submitted at the initial claim level or the Redetermination level, as the MAC will provide that to the QIC. However, if you have any additional documentation to support your requests, you should submit that with your request for Reconsideration.  We strongly recommend that you include a copy of your redetermination notice with your request.

Please Note: You may not request a Reconsideration before the a Redetermination has been completed. 

Part B Reconsideration requests should be mailed to the QIC at:

C2C Innovative Solutions, Inc. 
QIC Part B South
PO Box 45300
Jacksonville, FL 32232–5300

 

 Additional Resources

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now