![]() An explanation of why you think the items and/or services should be covered.Or, list the specific items and/or services for which you're requesting a redetermination, and the dates of service. Circle the items and/or services you disagree with on the MSN.Your name, address, and the Medicare Number on your Medicare card.Include this information in your written request:.Or, send a written request to company that handles claims for Medicare to the address on the MSN.Their address is listed in the "Appeals Information" section of the MSN. ![]()
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