42 CFR §405.964

1. (a)Filing location. The request for reconsideration must be filed with the QIC indicated on the notice of redetermination.
2. (b)Content of reconsideration request. The request for reconsideration must be in writing and should be made on a standard CMS form. A written request that is not made on a standard CMS form is accepted if it contains the same required elements, as follows:
   1. (1)The beneficiary's name;
   2. (2)Medicare number;
   3. (3)Specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service;
   4. (4)The name of the party or the representative of the party; and
   5. (5)The name of the contractor that made the redetermination.
3. (c)Requests for reconsideration by more than one party. If more than one party timely files a request for reconsideration on the same claim before a reconsideration is made on the first timely filed request, the QIC must consolidate the separate requests into one proceeding and issue one reconsideration.