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This booklet informs health care providers about Medicare's 5 appeal levels in Fee-for-Service (FFS). Check the "Adverse Determination" box under Appeal Type. •.Complete sections 1-4. Please describe the authorization or precertification issue that affected your claim payment in as much detail as possible. Send a completed "Model Coverage Determination Request" form. Or, mail or fax your appeal – You can send in your completed appeals form or write a letter asking for an appeal. Read all of these instructions. Your health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances. Complete your protest and mail it to the IRS address on the letter that explains your appeal rights. Completing your appeal online may take 40 to 60 minutes.