Office of Medicare Hearings and Appeals

When and How Can I Appeal?
If you wish to appeal, you must make your request in writing within 60 days from the date you receive the reconsideration decision from the Qualified Independent Contractor (QIC). We assume you receive the letter five days after the date on the letter, unless you can show us you received it later. In addition, your appeal must be above a certain dollar amount that will be adjusted annually in order for you to request an ALJ hearing. Call your OMHA field office if you need help with your appeal.

How Many Appeal Levels Are There?
Generally, there are five levels of appeal after you receive your initial determination. They are:

• Redetermination by an Affiliated Contractor (or Fiscal Intermediary or Carrier)
• Reconsideration by a Qualified Independent Contractor (QIC);
• A Hearing by an Administrative Law Judge;
• Review by the Medicare Appeals Council; and
• Review by a Federal District Court.

When OMHA sends you a letter about a decision on your appeal, we will tell you how to appeal the ALJ decision.

What Is a Reconsideration?
Reconsideration is a complete review of your claim by a Qualified Independent Contractor that did not take part in the initial determination or redetermination.

The Qualified Independent Contractor will look at the initial determination and re-determination, including all the evidence submitted when the initial determination or redetermination was made, plus any new evidence.

Asking for a Hearing
If you disagree with the reconsideration decision, you may ask for a hearing. An ALJ who had no part in the initial determination, redetermination, or the reconsideration of your case will conduct the hearing. The ALJ will notify you of the time and place of the hearing.

In general, hearings will be conducted by videoteleconference (VTC) or telephone, unless the ALJ determines that VTC is not available, or special or extraordinary circumstances exist, or you request an in-person hearing and your request is granted for good cause.

During the hearing, the ALJ will question you and any witnesses you bring to the hearing. Other witnesses, such as medical and non-medical experts, also may provide information at the hearing.

After the hearing, we will send you a letter and a copy of the ALJ’s decision for your case.

Filing Suit in Federal Court
If you disagree with the Medicare Appeals Council decision or if the Medicare Appeals Council decides not to review your case, you may be able to file a lawsuit in a federal district court. The Medicare Appeals Council notice of decision or letter denying review of an ALJ decision will give general information about filing a court complaint. It is not appropriate, however, for the Medicare Appeals Council to offer advice or assistance concerning whether, and how, an appellant may seek court review.

Can Someone Help Me?
Yes. Many people handle their own Medicare appeals, but you can choose a lawyer, a friend or someone else to help you. Someone you authorize or appoint to help you is called your “representative.” We will work with your representative just as we would work with you.

Your representative can act for you and will receive a copy of any decisions we make about your appeal. For more information, see Your Right to Representation