FAQs - Requesting an ALJ Hearing

Who can request a hearing with OMHA?

Medicare beneficiaries, providers, or suppliers (as well as applicable plans and Medicaid State Agencies under certain circumstances) are eligible to request hearings or review with the Office of Medicare Hearings and Appeals (OMHA).  OMHA is responsible for the third level of the Medicare claims appeals process. You can request a hearing with OMHA if you are dissatisfied with a decision or dismissal made by a Qualified Independent Contractor (QIC), Quality Improvement Organization (QIO), Independent Review Entity (IRE), or the Social Security Administration (related to eligibility, entitlement, and income-related premiums) and you meet the amount in controversy (AIC) requirement and file within 60 days of receiving  the decision that you are appealing.  We assume you received the decision that you are appealing 5 days after it is dated unless you provide evidence that you received it later than 5 days.  Any request for an extension of time must be filed with the Request for Hearing.  

What do I need to know to request a Medicare hearing with an Administrative Law Judge (ALJ)?

You have the right to appeal any issue not decided entirely in your favor regarding your Medicare eligibility, enrollment, premium, or coverage of items or services under Part A & B, Part C, or Part D of the Medicare program.

You can request a hearing before an Administrative Law Judge (ALJ) if you are dissatisfied with the decisions made at the prior level of the appeals process.  You will also have to meet the amount in controversy (AIC) requirement.   

The AIC requirement is recalculated and published on an annual basis, and is identified in your reconsideration or reconsideration determination.  Please note, your claim appeal can be aggregated with others to reach this threshold if:

At each level, you will receive written instructions on how to continue to the next level of appeal if you wish to do so.

How is the amount in controversy (AIC) calculated?

For appeals filed in calendar year 2021, the minimum amount in controversy required for an Administrative Law Judge hearing or review of a dismissal is $180. For reconsiderations issued by a Quality Improvement Organization, the minimum amount in controversy is $200.

The amount in controversy is generally calculated in the following manner:

• You specifically request aggregation of the claims in the same request for ALJ hearing, or in multiple requests for hearing filed with the same request for aggregation;
• The claims were previously reconsidered by a QIC;
• Your request for hearing lists all claims to be aggregated and is filed within 60 calendar days after receipt of all reconsiderations being appealed; and
• The OMHA adjudicator determines that the claims involve similar or related services.    

1. Amount charged minus Medicare payments already made or awarded = subtotal balance
2. Subtotal balance minus any applicable deductible/coinsurance that may be collected = amount in controversy

Example:
Amount charged:  $500
Medicare payment made:  $0
____________________________________
Subtotal balance:  $500
Copayment:  - 100
____________________________________
Balance:  $400
____________________________________
Amount in controversy:  $400

How do I file a Request for ALJ Hearing?

Please locate the reconsideration decision letter you received that you now want to appeal. Please refer to the last page which provides “Important Information About Your Appeal Rights.” You should read this information carefully because it includes instructions about how and where to request an ALJ Hearing.

OMHA Central Operations
1001 Lakeside Ave., Suite 930
Cleveland, OH 44114-1158

The address above is effective December 13, 2019.

Note:  If you are a beneficiary filing an appeal, please include the following as part of the address:  

                 Attn:  Beneficiary Mail Stop 

The best way to ensure your request reflects all the required elements is to use the form Request for Administrative Law Judge Hearing or Review of Dismissal, which prompts you for all the necessary information: OMHA-100.

The request must be in writing and generally it must include (with the exception of appeals related to Part C) the following information, if you choose not to use the Request for ALJ Hearing form:

1. The appellant’s name, address, and telephone number;
2. The beneficiary’s name, address, telephone number, and Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier);
3. If appropriate, the name, telephone number, address of the appellant’s designated representative;
4. The appeal number (Medicare Appeal Number or Medicare Case Identification Number) that appeared on the reconsideration decision or dismissal
5. The dates of service being appealed (not applicable to entitlement/IRMAA);
6. The reasons the appellant disagrees with the reconsideration being appealed; and
7. A statement of any additional evidence to be submitted and the date it will be submitted.

You must also send a copy of the Request for Hearing to the other parties who received a copy of the reconsideration that you are appealing, if any (hint: look at the CC (or copy) section of the notice).

I have a Medicare Advantage Plan.  How should I file a Request for Hearing?

Please locate the reconsidered determination letter you received that you now want to appeal.  Please complete the ALJ Hearing Request Form included with the reconsidered determination letter you received.  Mail the completed ALJ Hearing Request Form to the MAXIMUS Federal Services address provided in your reconsidered determination letter.    

How and where do I file an Expedited Part D Request?

Please locate the reconsideration decision letter you received that you now want to appeal. Please refer to the last page which provides “Important Information About Your Appeal Rights.” You should read this information carefully because it includes instructions about how to expedite your appeal.

To submit an Expedited Part D appeal by phone or fax, please use the following numbers:

Expedited Appeal Request Phone: (866) 941-7012

Expedited Appeal Request Fax: (216) 615-4116

To submit by mail, Expedited Part D appeals are to be sent to the following address:

OMHA Central Operations
Attn: Expedited Part D Appeal
1001 Lakeside Ave., Suite 930
Cleveland, OH 44114-1158

The address above is effective December 13, 2019.

Also, whether you submit an oral, fax or mail request, please include the following information:

1. The name, address, telephone number, and Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier) of the enrollee.
2. The name, address, and telephone number of the appointed representative, if any.
3. The appeals case number assigned to the reconsideration decision by the IRE.
4. The prescription drug in dispute.
5. The plan name.
6. The reasons you disagree with the reconsideration decision.
7. A statement of any additional evidence to be submitted and the date it will be submitted.
8. A statement that the enrollee is requesting an expedited hearing, if applicable.

Please Note:  An expedited hearing can only be provided if an appeal involves a coverage determination that is not solely a request for payment, and the Medicare enrollee’s prescribing physician or other prescriber indicates, or the OMHA adjudicator determines, that applying the standard timeframe for making a decision may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function.

How do I appeal a determination of the Income-Related Monthly Adjustment Amount for my Part B Supplementary Medical Insurance or Part D Prescription Drug benefit premium?

The procedure for appealing an Income-Related Monthly Adjustment Amount is described in the section titled Part B Premium Appeals.

How do I file a request for an extension?

If you miss the 60-day deadline to file your request for hearing, you must explain in writing why your request is late and ask the OMHA adjudicator to extend the deadline.  See "Request for Extension of Time to File Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal (Form OMHA-103)" - PDF.  For expedited Part D appeals requests may be in writing or oral.

Please file your request for an extension with your request for hearing.  If the OMHA adjudicator finds good cause for missing the deadline, the time period for filing the hearing request may be extended.

How do I submit additional evidence or documentation?

In order to manage the volume of appeals we are receiving, we ask that you please do the following:

• Submit any evidence you wish to have considered with the request for hearing or indicate in your request for hearing the date the evidence will be submitted. Any evidence submitted by a provider, supplier, or beneficiary represented by a provider or supplier that is being submitted for the first time must be accompanied by a statement explaining why the evidence was not previously submitted to the QIC, or a prior decision-maker or the evidence will not be considered.

• An OMHA adjudicator will then examine any new evidence to determine whether there is good cause to submit the evidence for the first time to OMHA. 
• Clearly list the Reconsideration (Medicare Appeal or Case) Number for the determination or dismissal you are appealing on your request for ALJ hearing form.  This number is typically located in the upper right-hand corner of the reconsideration decision letter in the following format: 1-1234567890.  Alternatively, please include a copy of the first page of your reconsideration decision. 
• If you are appealing a reconsideration issued by a Qualified Independent Contractor (QIC), DO NOT submit a courtesy copy of your request for ALJ hearing to the QIC who issued your reconsideration or to the Medicare Administrative Contractor (MAC) who issued your redetermination.  Neither the QIC nor the MAC require a copy for the purposes of 42 CFR § 405.1014(b)(2). 

• Do not re-submit medical records or other documentary evidence you already submitted earlier in the claim submission or to another level of appeal.  When you request an ALJ hearing, OMHA coordinates directly with the prior level of appeal to obtain the administrative record, which includes everything you already submitted.  Duplicate evidence will not be considered.

OMHA requests all previously submitted medical records or other documentary evidence from the Prior Appeal Level. The documents are then forwarded to OMHA for consideration.   

Now that I’ve submitted my Request for Hearing, what happens next?

Your request for hearing will be docketed and held in the Division of Central Operations until assigned to an OMHA adjudicator.  Due to the large volume of appeals currently in process, adjudication capacity is limited.  When your appeal is assigned to an adjudicator, the adjudicator will then review your appeal. Typically the first step the adjudicator will take will be to review your request to ensure all requirements are met.  

If your appeal requires an ALJ hearing, an ALJ will schedule one.  Once the hearing is scheduled, you will receive a document called a “Notice of Hearing.” That document will have the date, time and location of your hearing and additional instructions, all of which you should read carefully.

In some instances, an OMHA adjudicator may decide a case on the record, meaning that the adjudicator will issue a decision without conducting a hearing. However, this only happens if the decision is favorable to the appellant on every issue, no other party is liable for the non-covered claims, and CMS has not elected to be a party to the hearing; or if all the parties who would be sent a notice of hearing waived their right to appear before an ALJ at a hearing. 

You can find more information regarding the appeal process by going to www.hhs.gov/omha home page and reading information under each of the links on the left side of the screen.

I just received a Notice of ALJ Hearing in the mail. Why did I receive it and what do I have to do?

You received the notice of hearing because the ALJ determined that you are a party to a Medicare claim appeal who was found liable for the services or items at issue in a prior decision or may be found liable based on a review of the record.  The notice itself provides the time and place when the ALJ will conduct a hearing, and it also describes the specific issues that the ALJ will ultimately decide. Please read the notice carefully because it includes instructions and additional contact information if you have any other questions concerning this appeal. If you still have questions concerning the pending hearing after reading the notice, please contact the assigned ALJ team using the information provided on the notice.

Please note:  An expedited hearing can only be provided if an appeal involves a coverage determination that is not solely a request for payment, and the Medicare enrollee’s prescribing physician or other prescriber indicates, or the Administrative Law Judge determines, that applying the standard timeframe for making a decision may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function.

I just received a Notice of ALJ Hearing in the mail.  Do I have to attend? 

OR 

I just received a Notice of ALJ Hearing in the mail, but I didn’t appeal anything. 

You received the notice of hearing because the ALJ determined that you are a party who was found liable for the services or items at issue in a prior decision or may be found liable based on a review of the record. The request for hearing may have been filed by a provider or supplier, or another party. If you have more specific questions about why you received a notice, please contact the assigned ALJ team using the information provided on the notice.

I just received a Notice of ALJ Hearing which says that my appeal is with an ALJ in Arlington/Cleveland/Irvine/Kansas City/Miami/Seattle.  I don’t live in that area and I have no transportation.  What do I do?  

You are not required to appear in person at the ALJ Hearing. You may participate remotely by telephone or you can participate by video-teleconference (VTC) at a VTC site near you. Please read your notice of hearing carefully because it includes instructions and additional contact information if you have any other questions concerning this appeal. If you have more specific questions about your hearing, please contact the assigned ALJ team using the information provided on the notice.

What is a Video Teleconference (VTC) Hearing and how does it work?

A video-teleconference, or VTC, hearing utilizes video cameras and television screen technology so that you can participate in the hearing without traveling to the hearing office. Unlike a telephone hearing, VTC allows you and the ALJ to see and hear one another.

If you request a VTC hearing, the ALJ’s legal assistant will coordinate with a VTC site in your location where you will have to travel at the designated time and place. If you have more specific questions about VTC availability, please contact the assigned ALJ team using the information provided on the notice.

How do I change my hearing date or hearing type?

Please contact the assigned ALJ team using the information provided on your notice of hearing.

What happens during a hearing? 

OR 

What will the hearing be like? 

An administrative hearing is proceeding in which the ALJ collects testimony related to the items or services at issue. In many cases the hearing can be conducted by telephone. The hearing is recorded and made part of the official file (also known as the administrative record). Generally, you and any witnesses who are present will be sworn in and the ALJ will ask you questions related to the claim. At some point after the hearing the ALJ will consider all the evidence in the case, including your hearing testimony, and then issue a written decision.

If you have more specific questions concerning your hearing, please contact the assigned ALJ team using the information provided on your notice of hearing.

Has my request for hearing or review been received? 

OR 

What Field Office and OMHA adjudicator has my case been assigned to? 

OR 

What is the status of my appeal? 

OR 

I submitted a request, how much longer do I have to wait for a hearing? 

Although OMHA is processing a record number of Medicare appeals, we continue to receive more requests for hearing than our adjudicators can adjudicate in a timely manner.  Your request will be processed in the order received as quickly as possible given pending requests.  We will continue to process Part D prescription drug denial cases that qualify for expedited status within 10 days and will screen all incoming requests to ensure Medicare beneficiary issues are prioritized given that they often present emergent circumstances that must be promptly addressed.  In all other circumstances, you (or your representative) will receive an Acknowledgement of Request letter when your request is processed.  Further information about processing time is posted on the Workload Information and Statistics page on our website.

To check on the status of your appeal, you may access OMHA’s ALJ Appeal Status Information System (AASIS) at http://aasis.omha.hhs.gov. The data in AASIS are updated weekly, usually on Tuesday. The date of the last update can be found at the bottom of the AASIS inquiry page. It is important to note that appeals that were decided or otherwise closed more than 180 days ago will not appear in the system.

I received a remand order that says OMHA doesn’t have the case file. What do I need to do?

You received a copy of the remand order as a courtesy so that you have the current procedural status of your appeal. The order directs the prior appeal level to forward the case file or other information essential to resolving your appeal to our office so the adjudicator can proceed with the case. There is nothing you need to do.

You have the right to request the Chief ALJ or designee to review the remand within 30 days of receiving notice of a remand. The Chief ALJ or designee will review the remand, and if the remand is not authorized by this section, vacate the remand order. The determination on a request to review a remand order is binding and not subject to further review. See 42 CFR § 405.1056(g).

What is the timeline on the hearings and appeals process?

The timeline for issuing a decision differs depending on the type of Medicare you have, the level of the appeal, and certain special circumstances.  To learn more, see the Appeals Process. The time period for OMHA to issue decisions on cases at this level of the appeals process is generally 90 days. However we regret that due to the large volume of appeals currently in process, your appeal most likely will not be completed within 90 days, though expedited Part D appeals will continue to be processed within 10 days.  Please be assured that the OMHA adjudicators and their staff are processing hearing requests as quickly as possible.  OMHA is committed to providing the most timely decisions possible for all pending appeals.

It’s been over 90 days and I still haven’t received a decision from OMHA. How do I escalate my case to the next level?

For instructions on how to request that your case be escalated to the Medicare Appeals Council, please visit the Escalation Rights page on the OMHA website at https://www.hhs.gov/about/agencies/omha/filing-an-appeal/coverage-and-claims-appeals/escalation-rights/index.html

Do I need a representative? 

OR 

Do I need to hire an attorney? 

OR 

How do I obtain an attorney? 

You are not required to be represented and if you wish to be represented, you are not required to obtain an attorney. If you decide to seek representation, and obtain a representative, you and your appointed representative will need to complete an Appointment of Representative Form and submit it to the assigned OMHA adjudicator.  You can find this form by going to the forms page of our website.

How do I appoint a person to represent me in a Medicare appeal?

The procedure for appointing a representative is described in the section titled Your Right to Representation.

How long will my appointed representative remain my representative?

Unless revoked, an appointment is considered valid for one year from the date the form is signed. Once the form is filed, it is valid for the duration of the appeal. Therefore, a signed form can be used for more than one appeal as long as the appeal is filed within one year of the date on the form.

My medical bill has gone into collections, what do I do? 

OMHA has no jurisdiction over collections and OMHA cannot provide you with advice or stop the collections process.

Does Medicare have a Toll Free number? 

Yes. You may call a Medicare representative at 1-800-633-4227. Hearing and speech impaired individuals may call their toll-free TTY/TDD number at 1-877-486-2048 during regular business hours.

I disagree with the OMHA adjudicator’s decision, remand or dismissal. What do I do next? 

OR 

I want to appeal the . What do I do next? 

Please refer to the notice document, which was issued with the adjudicator's decision, remand, or dismissal. Generally, if you disagree with the adjudicator’s decision or dismissal, you must submit a written request for review with the Medicare Appeals Council within 60 calendar days of receiving the decision or dismissal at the following address:

Department of Health and Human Services
Departmental Appeals Board
Medicare Appeals Council, MS 6127
Cohen Building Room G-644
330 Independence Ave., S.W.
Washington, D.C. 20201

To help process your request for review as quickly as possible the Medicare Appeals Council suggests using its Request for Review form, the DAB-101.

You have the right to request the Chief ALJ or designee to review any remand order issued by an OMHA adjudicator within 30 days of receiving notice of a remand. The Chief ALJ or designee will review the remand, and if the remand is not authorized by this section, vacate the remand order. The determination on a request to review a remand order is binding and not subject to further review. See 42 CFR § 405.1056(g).

I received a favorable decision a while ago but I still haven’t received a reimbursement. I need to speak to someone about this.

OMHA is not involved in effectuating claims for payment.

If you are a Medicare beneficiary, contact 1-800-MEDICARE (633-4227).

If you are a Medicare provider or supplier, contact the Medicare Administrative Contractor that initially processed the claim.