An explanation of why you think the items and/or services should be covered.Or, list the specific items and/or services for which you're requesting a redetermination, and the dates of service. Circle the items and/or services you disagree with on the MSN.Your name, address, and the Medicare Number on your Medicare card.Include this information in your written request:.Or, send a written request to company that handles claims for Medicare to the address on the MSN.Their address is listed in the "Appeals Information" section of the MSN. Fill out a " Redetermination Request Form " and send it to the company that handles claims for Medicare.If you missed the deadline for appealing, you may still file an appeal and get a decision if you can show good cause for missing the deadline. You must file your appeal by the date in the MSN. If you have Original Medicare, start by looking at your " Medicare Summary Notice" (MSN).An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines.If Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need.A request to change the amount you must pay for a health care service, supply, item, or drug.A request for payment of a health care service, supply, item, or drug you already got.A request for a health care service, supply, item, or drug you think Medicare should cover.For example, you can appeal if Medicare or your plan denies: An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan.
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