Office of Medicare Hearings and Appeals (OMHA)
After the ALJ Decision
|This section covers only OMHA’s role at Level 3 of the appeals process. The appeals process begins at Level 1.In order to appeal to OMHA, you must have passed through Level 1 and Level 2 of the appeals process. For more information, see " Understanding the Appeals Process".|
How and When You Will be Notified of the Hearing Decision
- You will be notified of your hearing decision by U.S. mail.
- Generally you will receive the decision within 90 days of your hearing request, but keep in mind that each case is unique. Under certain circumstances the 90 day time frame to decide your case may be extended.
- In some instances, if the ALJ does not issue a decision within the 90 day period, you may request escalation of your appeal to the Medicare Appeals Council (MAC).
When the ALJ Issues a Decision Favorable to YouIf the ALJ finds in your favor and that your claim should be paid by Medicare, your case is forwarded to the CMS Medicare contractor for effectuation. This means it is the Medicare contractor and not the ALJ who is responsible to pay the claim according to the ALJ decision and applicable Medicare payment policies. Therefore, any questions you may have regarding Medicare payment following a favorable ALJ decision should be directed to the Medicare contractor and not OMHA.
When the ALJ Issues a Decision that is Not Favorable to YouIf you are not satisfied with the ALJ decision, you may request that the Medicare Appeals Council (MAC) review your case. Your request for the MAC to review your claim must be made within 60 days of the date you receive the OMHA ALJ hearing decision. If you are unable to meet this deadline, explain your reasons for missing it in your request. An appeal to the Medicare Appeals Council is referred to as a “request for review.”
Note: A party does not have the right to seek MAC review of an ALJ's remand to a QIC or an ALJ's affirmation of a QIC's dismissal of a request for reconsideration.