Part B/DEM Requesting an Appeal

Requesting a Part B Appeal

This process applies to all redetermination decisions processed by MACs on or after Jan. 1, 2006.

After a claim has been denied by a MAC at the first level of appeal (redetermination), the beneficiary or his/her representative may request a reconsideration from a Qualified Independent Contractor (QIC). QICs perform independent, on-the-record reviews of MAC redeterminations. The appellant’s right to a reconsideration will be explained in the redetermination 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
The beneficiary’s Medicare health insurance claim number
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
The name of the contractor that made the redetermination

Qualified Independent Contractor (QIC)	Jurisdiction By States
Part B North Reconsiderations Requests By Fax or Secure Online Portal Fax your appeal to the number at QIC Part B North OR Submit your appeal and documentation to C2C's secure portal through www.c2cinc.com. Requests By Mailing Address C2C Innovative Solutions, Inc. Part B North Reconsiderations PO Box 45208 Jacksonville, FL 32232-5208 Courier Address C2C Innovative Solutions, Inc. Part B Reconsiderations 301 W Bay St., Sixth Floor Jacksonville, FL 32202-5100 C2C Innovative Solutions Part B North QIC	Alaska, Maine, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, District of Columbia, New York, Pennsylvania, New Jersey, Delaware, Maryland, Ohio, Kentucky, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Missouri, Iowa, Kansas, Nebraska, South Dakota, North Dakota, Wyoming, Montana, Idaho, Washington, Oregon, California, Nevada, Arizona, Utah, Hawaii, Guam, Northern Mariana Islands, American Samoa
Part B South Reconsiderations Requests By Fax or Secure Online Portal Fax your appeal to the number at QIC Part B South OR Submit your appeal and documentation to C2C's secure portal through www.c2cinc.com. Requests By Mail C2C Innovative Solutions, Inc. Part B South Reconsiderations PO Box 45300 Jacksonville, FL 32232-5300 Correspondence/Files for Active Cases C2C Innovative Solutions, Inc. Part B South Correspondence PO Box 45301 Jacksonville, FL 32232-5301 Courier Address C2C Innovative Solutions, Inc. Part B South Reconsiderations 301 West Bay Street, Suite 600 Jacksonville, FL 32202 ALJ Related Correspondence Address C2C Innovative Solutions, Inc. Part B South ALJ Department P.O. Box 44006 Jacksonville, FL 32232-4006 C2C Innovative Solutions Part B South QIC	Colorado, Connecticut, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, Florida, North Carolina, South Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands
DME Reconsiderations Mailing Address MAXIMUS Federal DME QIC 3750 Monroe Avenue, Suite 777 Pittsford, NY 14534 Maximus DME QIC	Nationwide

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.