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Step 1 of 5Centers for Medicare & Medicaid Services · CMS-20031

CMS-20031 - Transfer of Appeal Rights

CMS-20031 lets a Medicare beneficiary transfer appeal rights for one listed item or service to the provider or supplier that furnished it.

Current step
Beneficiary information
Name of Medicare beneficiary, Medicare number, and Beneficiary phone number
This step
3 fields · 3 required

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Step 1

Beneficiary information

This transfer applies only to the item or service listed in this form. If the provider accepts your appeal rights, they cannot bill you for that item or service except for applicable deductible or coinsurance amounts unless you cancel the transfer or previously signed an Advance Beneficiary Notice. You can cancel the transfer later in writing.

3 required

Need more context?

The form is ready to fill now. If you want supporting instructions, mailing notes, or source links, they are below.

What you need+
  • Beneficiary name, Medicare number, and phone number
  • The specific item or service connected to the appeal
  • Provider or supplier contact details
  • Beneficiary signature and provider acceptance signature with dates
  • Signed form (wet signature required)
  • Supporting claim documents (optional) (optional) — Attach claim notices, denial letters, or medical documentation that supports the appeal transfer.
How it works+
  1. Fill out the form
  2. Add attachments
  3. Preview the PDF
  4. Mail it
Where it gets mailed+

Enter the recipient address during checkout.

Packet order+
  • Cover sheet (auto-generated)
  • Completed form PDF
  • Attachments (in the order you upload)
Common mistakes+
  • Treating the form as a blanket transfer for every Medicare claim instead of one listed item or service.
  • Listing a provider who did not furnish the item or service at issue.
  • Missing either the beneficiary signature or the provider acceptance signature.
  • Forgetting that the beneficiary can lose the right to appeal that item or service directly unless the transfer is canceled in writing.
FAQs+
Does this transfer apply to all of my Medicare claims?

No. The transfer applies only to the specific item or service identified in this form.

What happens after I transfer my appeal rights?

The provider or supplier may pursue the appeal with Medicare for the listed item or service, and you generally will not appeal that denial yourself.

Can I cancel the transfer later?

Yes. You can cancel the transfer later in writing.

Sources+
Related+
Last verified+

Last Centers for Medicare & Medicaid Services verification: March 20, 2026