--- title: CMS-20033 Medicare reconsideration request description: Prepare Form CMS-20033 with a guided online workflow instead of handwriting the paper form. seotitle: CMS-20033 Medicare reconsideration request seo-description: Prepare Form CMS-20033 with a guided online workflow instead of handwriting the paper form. group: resources indexable: true llms: true schema: webpage tags: - medicare - appeals - claims path: /forms/cms-20033 --- # CMS-20033 Medicare reconsideration request Prepare Form CMS-20033 with a guided online workflow instead of handwriting the paper form. ## How it works 1. **Enter the beneficiary and claim details from the Medicare paperwork.** - 2. **Explain why the redetermination was wrong and add any extra information Medicare should consider.** - 3. **Choose whether you are submitting evidence and identify who is filing the appeal.** - 4. **Upload the redetermination notice and any supporting evidence, then mail the completed packet.** - ## Form summary PostalForm turns CMS-20033 into an online-native Medicare appeal workflow. You answer one step at a time, generate a clean PDF, attach the required redetermination notice, and mail the completed packet to the address listed in your Medicare appeal materials. ## What you need - Beneficiary name and Medicare number - The item or service being appealed - Date of service and date of the redetermination notice - Short explanation of why you disagree - Mailing address and phone number for the appellant - Copy of the redetermination notice - Copy of the redetermination notice (required) — CMS says to include a copy of the Medicare Redetermination Notice or Remittance Advice with this request. - Supporting evidence or statement (optional) — Attach evidence supporting the appeal, or a statement explaining what evidence you plan to submit and when. ## Data collected - Beneficiary identifying information - Medicare claim and redetermination details - Appeal explanation and supporting information - Appellant contact information ## Where it gets mailed You will enter the recipient address during checkout. ## Packet order - Cover sheet - Completed CMS-20033 form - Copy of the redetermination notice - Supporting evidence or statement of additional evidence ## Common mistakes - Mailing the packet without a copy of the redetermination notice. - Leaving out the claim explanation or writing only a very short disagreement statement. - Sending the packet to the wrong contractor instead of the QIC address listed in the appeal materials. - Skipping supporting evidence when you already have records that back up the appeal. ## Agent summary Use this online-native CMS-20033 workflow to prepare a clean reconsideration request packet you can print and mail to the correct Qualified Independent Contractor. ## For assistants Use the Forms Draft API to prefill this form and generate a preview PDF. - Endpoint: `POST /api/forms/cms-20033/drafts` - Payload: `{ fields: { ... }, attachments: [{ id, label, base64 }] }` - Required fields: beneficiary_name, medicare_number, appealed_item_or_service, service_received_date, redetermination_notice_date, disagreement_reason, evidence_yes, evidence_no, person_appealing_beneficiary, person_appealing_provider_supplier, person_appealing_representative, overpayment_yes, overpayment_no, appellant_name, appellant_street_address, appellant_city, appellant_state, appellant_zip, appellant_phone - Attachment IDs: redetermination_notice_copy, supporting_evidence - Notes: If the user does not know where to mail the appeal, instruct them to use the QIC address shown on the redetermination notice or other Medicare reconsideration instructions they received. ## LLM field schema ```json [ { "id": "beneficiary_name", "label": "Beneficiary name (first, middle, last)", "type": "text", "required": true, "meta_class": "name", "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "medicare_number", "label": "Medicare number", "type": "text", "required": true, "meta_class": null, "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appealed_item_or_service", "label": "Item or service you want to appeal", "type": "text", "required": true, "meta_class": null, "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "service_received_date", "label": "Date the service or item was received", "type": "text", "required": true, "meta_class": "date", "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "redetermination_notice_date", "label": "Date of the redetermination notice", "type": "text", "required": true, "meta_class": "date", "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "late_filing_reason", "label": "Reason for late filing if you received the notice more than 180 days ago", "type": "textarea", "required": false, "meta_class": null, "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "medicare_contractor_name", "label": "Name of the Medicare contractor that made the redetermination", "type": "text", "required": false, "meta_class": null, "ui_width": null, "group_id": "beneficiary", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "disagreement_reason", "label": "Why do you disagree with the redetermination decision?", "type": "textarea", "required": true, "meta_class": null, "ui_width": null, "group_id": "appeal_reason", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "additional_information", "label": "Additional information Medicare should consider", "type": "textarea", "required": false, "meta_class": null, "ui_width": null, "group_id": "appeal_reason", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "evidence_yes", "label": "I have evidence to submit", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "evidence", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "evidence_no", "label": "I do not have evidence to submit", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "evidence", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "person_appealing_beneficiary", "label": "Beneficiary", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "evidence", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "person_appealing_provider_supplier", "label": "Provider/Supplier", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "evidence", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "person_appealing_representative", "label": "Representative", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "evidence", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "overpayment_yes", "label": "Yes", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "overpayment", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "overpayment_no", "label": "No", "type": "checkbox", "required": true, "meta_class": "radio", "ui_width": null, "group_id": "overpayment", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_email", "label": "Email of person appealing (optional)", "type": "text", "required": false, "meta_class": "email", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_name", "label": "Name of person appealing (first, middle, last)", "type": "text", "required": true, "meta_class": "name", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_street_address", "label": "Street address of person appealing", "type": "text", "required": true, "meta_class": "address", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_city", "label": "City", "type": "text", "required": true, "meta_class": "city", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_state", "label": "State", "type": "text", "required": true, "meta_class": "state", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_zip", "label": "ZIP code", "type": "text", "required": true, "meta_class": "zip", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appellant_phone", "label": "Telephone number of person appealing", "type": "text", "required": true, "meta_class": "phone", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null }, { "id": "appeal_date", "label": "Date of appeal (optional)", "type": "text", "required": false, "meta_class": "date", "ui_width": null, "group_id": "appellant_contact", "choice_group": null, "choice_label": null, "visibility": null, "compound_subfields": null } ] ``` ## Sources - [CMS-20033 form page](https://www.cms.gov/cms20033-reconsideration-request-form) - [Official CMS-20033 PDF](https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms20033.pdf) - [Official instructions](https://www.cms.gov/cms20033-reconsideration-request-form) - [Official PDF](https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms20033.pdf) ## Last verified 2026-03-31 ## FAQs - **Can I fill out CMS-20033 online?** You can complete the information online with PostalForm, generate a clean CMS-20033 packet, and mail the finished form with the required attachments. - **Do I need to attach the redetermination notice?** Yes. CMS instructs appellants to include a copy of the redetermination notice with the reconsideration request. - **Where do I mail CMS-20033?** Mail it to the Qualified Independent Contractor listed in your Medicare appeal materials. The correct mailing address depends on the underlying appeal. ## Related - [CMS-20027 - Redetermination Request Form](/forms/cms-20027) - [CMS-20031 - Transfer of Appeal Rights](/forms/cms-20031) - [CMS-1490S](/forms/cms-1490s)