Request an expedited review if waiting could seriously harm your health — the plan must decide within 72 hours

Ask your doctor to submit a supporting statement explaining why the service is medically necessary

If the MA plan upholds the denial, it automatically goes to an Independent Review Entity — you do not need to file separately

Medicaremoderate

Part A/B Special Enrollment (Exceptional Conditions)

CMS-10797 · CMS

Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.

Form Details

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Where to Submit This Form

📬

Mail to your Medicare Advantage plan

Send to the address on your plan's denial or organization determination letter.

📠

Fax to your Medicare Advantage plan's appeals department

Fax number is on the denial notice.

Filing Deadline

60 days from the date of the organization determination you are appealing.

Required Attachments

📎 Copy of the organization determination (denial notice)
📎 Letter of medical necessity from your treating physician
📎 Relevant medical records supporting the requested service
📎 Any peer-reviewed clinical evidence supporting your request

Processing Time

Standard: 30 days for service requests, 60 days for payment requests. Expedited: 72 hours if delay could seriously jeopardize health.

What Happens Next

Your MA plan must issue a reconsideration decision. If upheld, the case is automatically forwarded to an Independent Review Entity (IRE) for external review.

Tips for This Form

✓ Request an expedited review if waiting could seriously harm your health — the plan must decide within 72 hours
✓ Ask your doctor to submit a supporting statement explaining why the service is medically necessary
✓ If the MA plan upholds the denial, it automatically goes to an Independent Review Entity — you do not need to file separately
✓ You can continue receiving a service during appeal if it was previously authorized and you request continuation within the deadline

More Medicare Forms

Medicare Part B Enrollment

CMS-40B · CMS

Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.

Request for Employment Information

CMS-L564 · CMS

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.

Part B Immunosuppressive Drug Coverage Enrollment

CMS-10798 · CMS

Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.

Medicare Advantage Enrollment

Plan-specific (CMS model template) · CMS

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Medicare Advantage Disenrollment

CMS model disenrollment form · CMS

Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

Medicare Redetermination Request

CMS-20027 · CMS

First-level appeal for Original Medicare (Part A/B) claim denials. Must be filed within 120 days of the initial determination.

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