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If an ALJ issued a decision after a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO), made a reconsideration or fair hearing determination, these procedures apply to your appeal:

If you do not agree with the Administrative Law Judge’s (ALJ’s) decision, you may appeal to the Medicare Appeals Council.  Other parties may appeal too.  We call an appeal to the Medicare Appeals Council a “request for review.”  The Medicare agency may also ask the Medicare Appeals Council to review the ALJ’s decision on its own motion.   

The ALJ’s decision will become final unless:

• The Medicare Appeals Council reviews the ALJ’s decision on the appeal of a party or on its own motion; or
• The Medicare Appeals Council denies the appeal of a party and a party asks for federal court review. 

You may appoint an attorney or other person to represent you.  Legal aid groups may provide legal services at no charge.

What to Include in your Appeal

You should use the form DAB-101 to appeal.  You may also appeal in writing if you provide:

• the beneficiary's name;
• the beneficiary's health insurance claim number;
• the item or service in dispute;
• the date of the item or service;
• the date of the ALJ’s decision; and
• your name and signature, or the name and signature of your representative;

Please send a copy of the ALJ’s decision with your appeal.  

How to File an Appeal

You must file an appeal within 60 days after you received the ALJ’s decision.  The Medicare Appeals Council will assume that you received the ALJ’s decision five days after the date shown on it, unless you show that you received it later.  If you file the appeal late, you must show that you had good cause. 

Mail the appeal to:

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.

Or you may fax the appeal to (202) 565-0227.  If you send a fax, please do not also mail a copy.  You may also file the appeal with any Social Security Office.  However, it will take longer to work on your case if you file anyplace except the Medicare Appeals Council.  You must send a copy of your appeal to the other parties.

The regulations at 20 C.F.R. Part 404, Subpart J, apply to this case.  If you have questions about the Medicare Appeals Council, you may call (202) 565-0100.

Medicare Appeals Council Action

The Medicare Appeals Council may deny, dismiss, or grant your appeal.  The Council will review the ALJ’s decision only if it finds present one of the reasons for review listed in the regulations at  20 C.F.R. ' 404.970.

If the Medicare Appeals Council decides to review your case, it may change the parts of the ALJ’s decision that you agree with.  The Council may adopt, change, or reverse the ALJ’s decision, in whole or in part, or it may send the case back to an ALJ for further action.  The Medicare Appeals Council may also dismiss the appeal to the ALJ.

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