Last Modified: 1/2/2019
Location: FL, PR, USVI
Business: Part B
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.Appeals forms
Providers, participating physicians, and other suppliers have the right to appeal claim decisions. Appeals must be submitted using the following forms:
First level: Request for redetermination of a Part B claim 
Second level: Reconsideration request form -- C2C Innovative Solutions Inc. Third level: Hearing by an administrative law judgeMinor error? Request a claim reopening
Did your claim have a clerical error or other minor discrepancy? Part B claims may be corrected outside of the appeals process.
Correct your claim online through the SPOT -- SPOT offers registered users the time-saving advantage of not only viewing claim data online but also the option of correcting clerical errors in their eligible Part B claims quickly, easily, and securely -- online. Correct your claim using the interactive voice response (IVR) -- The IVR allows providers/customers to call in to request reopenings on certain claims Correct your claim by writing in, using the first level of appeal (redetermination). Writing in allows you to supply additional information you feel is necessary to correct a claim.Additional resources
Learn how an individual can become an authorized beneficiary representative for appeals -- CMS 1696: Appointment of representative 
Understand when to file an appeal and the time limits for filing requestsFirst Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
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