CMS-20027 - Redetermination Request Form

CMS-20027 is used to request a redetermination (first-level Medicare appeal) for a claim decision.

Centers for Medicare & Medicaid Services · CMS-20027

Step 1 of 3

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What you need

Beneficiary identifying information
Claim item or service details
Reason you disagree with the determination
Appellant contact details and mailing address
Signed form (wet signature required)
Supporting appeal evidence (optional) (optional) — Attach claim notices, medical records, or other documentation supporting your redetermination request.

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Who should receive CMS-20027?

Send it to the Medicare Administrative Contractor identified on your Medicare Summary Notice or initial determination notice.

Can I include extra evidence?

Yes. You can attach records or documents that support your appeal.

Is this the first step in a Medicare appeal?

Yes. Redetermination is the first level of the Medicare claims appeal process.

Last Centers for Medicare & Medicaid Services verification: March 21, 2026