Requesting an Appeal

After a claim has been denied by a Part A MAC at the first level of appeal (redetermination). The beneficiary or his/her representative may request a reconsideration as indicated by the appeal notice.

A request for a reconsideration must either be made on CMS Form 20033 or written into a letter that must include the following information:

The beneficiary's name;
Medicare health insurance claim number (HICN);
The specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service;
The name of the party or representative of the party; and
The name of the contractor that made the redetermination

The Qualified Independent Contractor (QIC) that performs Part A reconsiderations is listed below, divided by East and West jurisdiction.

Qualified Independent Contractor (QIC)	States
Part A East Standard Reconsideration Requests Fax your appeal to the number at QIC Part A East OR Submit your appeal and documentation to C2C's secure portal through www.c2cinc.com. C2C Innovative Solutions, Inc. QIC Part A East Appeals PO Box 45305 Jacksonville, FL 32232-5305 Correspondence: C2C Innovative Solutions, Inc. QIC Part A East Correspondence PO Box 45307 Jacksonville, FL 32232-5307 Courier Address C2C Innovative Solutions, Inc. QIC Part A East Appeals 301 West Bay Street, 6th Floor Jacksonville, FL 32202 C2C Innovative Solutions	Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, Florida, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania, and District of Columbia
Part A West Maximus Federal Services Medicare Part A West 3750 Monroe Avenue, Suite 706 Pittsford, NY 14534 Maximus Federal Services	Washington, Idaho, Montana, North Dakota, South Dakota, Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, Arizona, Nevada, California, Alaska, Hawaii, Oregon, Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, Wisconsin, Guam, Northern Mariana Islands, and American Samoa

Qualified Independent Contractor (QIC)

States

Part A East

Standard Reconsideration Requests

Fax your appeal to the number at QIC Part A East OR Submit your appeal and documentation to C2C's secure portal through www.c2cinc.com.

C2C Innovative Solutions, Inc.
QIC Part A East Appeals
PO Box 45305
Jacksonville, FL 32232-5305

Correspondence:

C2C Innovative Solutions, Inc.
QIC Part A East Correspondence
PO Box 45307
Jacksonville, FL 32232-5307

Courier Address

C2C Innovative Solutions, Inc.
QIC Part A East Appeals
301 West Bay Street, 6th Floor
Jacksonville, FL 32202

C2C Innovative Solutions

Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, Florida, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania, and District of Columbia

Part A West
Maximus Federal Services
Medicare Part A West
3750 Monroe Avenue, Suite 706
Pittsford, NY 14534

Maximus Federal Services

Washington, Idaho, Montana, North Dakota, South Dakota, Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, Arizona, Nevada, California, Alaska, Hawaii, Oregon, Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, Wisconsin, Guam, Northern Mariana Islands, and American Samoa

NOTE:
If you have filed an appeal request with a QIC, but have decided to retract that appeal request, you can do so according to 42 CFR § 405.972.

This regulation states that you may file a written and signed request for withdrawal with the appropriate QIC. The contents of this request for withdrawal must include a clear statement that the appellant is withdrawing the request and does not intend to proceed further with the appeal. The request for withdrawal must also be received in the QIC’s mailroom before the reconsideration is issued.