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Last Modified: 10/11/2017 Location: FL, PR, USVI Business: Part A

Appeals forms

Providers, participating physicians, and other suppliers have the right to appeal claim decisions. Appeals must be submitted using the following forms:
more 1st level: Request for redetermination of a Part A claim
Florida pdf file
more 2nd level: Reconsideration request form -- C2C Innovative Solutions, Inc.
Florida pdf file
more 3rd level: Hearing by an administrative law judge
more 4th level: Medicare Appeals Council

Exception for timely filing

There are a few exceptions which allow an extension to the 12-month timely filing period. View the following resources for additional information.

Additional resources

more Understand when to file an appeal and the time limits for filing requests
First 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.