Coverage and Claims Appeals

OMHA is in charge of Level 3 of the coverage and claims appeals process.  In order to appeal to OMHA, you must have passed through Level 1 and Level 2 of the appeals process.  For more information, see "The Appeals Process."

At Level 3 of the appeals process, your appeal will be reviewed by an OMHA adjudicator, and you may have a hearing before an Administrative Law Judge (ALJ).  This gives you the opportunity to present your appeal to a new person who will independently review the facts of your appeal and make a new and impartial decision in accordance with the applicable law. If you have a hearing before an OMHA ALJ, the ALJ will also listen to your testimony before making a decision in accordance with the applicable law.
In some instances, an OMHA adjudicator may decide a case on the record if all parties who would be sent a notice of hearing waive their rights to an oral hearing or when the documentary evidence supports a finding fully favorable to the appellant, and no other party to the appeal would be financially responsible for any of the claims at issue.

Medicare Beneficiary and Medicare Advantage Part C Plan Enrollee or Part D Plan Enrollee Appeals and Assistance


To help ensure Medicare Beneficiary and Enrollee appeals are adjudicated as quickly as possible, OMHA designates appeals filed by Beneficiaries and Enrollees as priority appeals, with some exceptions.Learn more about appeals and assistance.

In this section of the web site, you will find the following:

Topic Description
Request an ALJ Hearing
  • Requirements for an Appeal
  • How to Submit a Request for an appeal
  • Setting Up Your ALJ Hearing
  • Requesting an In-person Hearing
  • Information on Video-Teleconferencing (VTC)
Tips for Filing a Request for ALJ Hearing or Review of Dismissal
  • Where to File
  • What Information to Include
  • Filing Time Frame
  • Multiple Beneficiaries
  • Grouping Multiple Requests for Hearing
  • Aggregating Claims to Meet the Amount in Controversy
  • Withdrawing a Request for Hearing or Review of a Dismissal
Your ALJ Hearing
  • What to Expect from the ALJ During the Hearing
  • Canceling an ALJ Hearing
Documents for Your Hearing
  • Viewing your Current Case File
  • Submitting New Evidence
  • How OMHA Manages your Documents
After the OMHA Adjudicator's Decision, Remand, or Dismissal
  • How and When You Will be Notified of the OMHA adjudicator's Determination on your Appeal
  • When the OMHA adjudicator Makes a Determination that is Favorable to You
  • When the OMHA adjudicator Makes a Determination that is Not Favorable to You
Tips for a Timely Review
  • Things you can do to assist the processing of your request for hearing


Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed