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Court telephone no. 1. A redetermination is the first appeal level after the initial claim determination.By filing an internal appeal, you are requesting your health plan to review the denial decision in a fair and complete way. A sample completed Appeal. Form (see Figure 1) and detailed instructions are on a following page. You'll need to download and fill out a Decision Review Request: Supplemental Claim (VA Form 200995). A sample completed Appeal. Form (see Figure 1) and detailed instructions are on a following page. We find that, across HealthCare. Do not use the form for formal claims appeals or disputes.