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OMHA FAQs - Requesting an ALJ Hearing

CategoryQuestions
My Appeal
  • Who can request a hearing with OMHA? [Answer]
  • What do I need to know to request a Medicare hearing with an Administrative law Judge(ALJ)? [Answer]
  • How is the amount in controversy (AIC) calculated? [Answer]
  • How do I file a request for ALJ Hearing? [Answer]
  • I have a Medicare Advantage Plan.  How should I file a Request for Hearing? [Answer]
  • How and where do I file an Expedited Part D Request? [Answer]
  • 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? [Answer]
  • How do I file a request for an extension? [Answer]
  • How do I submit additional evidence or documentation? [Answer]
My Hearing
  • Now that I’ve submitted my Request for Hearing, what happens next? [Answer]
  • I just received a Notice of ALJ Hearing in the mail. Why did I receive it and what do I have to do? [Answer]
  • 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. [Answer]
  • I just received a Notice of ALJ Hearing which says that my appeal is with a Judge in Irvine/Cleveland/Arlington/Miami. I don’t live in that area and I have no transportation. What do I do? [Answer]
  • What is a Video Teleconference Hearing and how does it work? [Answer]
  • How do I change my hearing date or hearing type? [Answer]
  • What happens during a hearing?
    OR
    What will the hearing be like? [Answer]
My Status
  • Has my Request for Hearing been received?
    OR
    What Field Office and ALJ has my case been assigned to?
    OR
    What is the status of my appeal?
    OR
    I submitted a RFH, how much longer do I have to wait for a Hearing? [Answer]
  • I received an ALJ remand order that says the Judge doesn’t have the case file. What do I need to do? [Answer]
  • What is the timeline on the hearings and appeals process? [Answer]
  • It’s been over 90 days and I still haven’t received an ALJ decision. How do I escalate my case to the next level? [Answer]
My Representation
  • Do I need a representative?
    OR
    Do I need to hire an attorney?
    OR
    How do I obtain an attorney? [Answer]
  • How do I appoint a person to represent me in a Medicare appeal? [Answer]
  • How long will my appointed representative remain my representative? [Answer]
  • My medical bill has gone into collections, what do I do? [Answer]
  • Does Medicare have a Toll Free number? [Answer]
After My ALJ Decision
  • I disagree with the ALJ’s Decision. What do I do next?
    OR
    I want to appeal the ALJ’s decision. What do I do next? [Answer]
  • I received a favorable ALJ decision a while ago but I still haven’t received a reimbursement. I need to speak to someone about this. [Answer]

 

Who can request a hearing with OMHA?

Medicare beneficiaries, providers, or suppliers are eligible to request hearings with the Office of Medicare Hearings and Appeals (OMHA).  OMHA handles the Administrative Law Judge (ALJ) - Level  in the Medicare claims appeals process. You can request a hearing with OMHA if you are dissatisfied with a decision 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.   

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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:

  • You specifically request 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 ALJ determines that the claims involve similar or related services.    

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

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How is the Amount in Controversy (AIC) calculated?

The amount in controversy is calculated in the following manner:

1. Amount Charged minus Medicare payments already made or awarded = Subtotal Balance

2. Subtotal Balance minus any applicable Deductible/Coinsurance = Amount in Controversy

Example:

Amount Charged:  $500
Medicare payment made:  $0
____________________________________
Subtotal Balance:  $500
Copayment:  - 100
____________________________________
Balance:  $400
____________________________________
Amount in Controversy:  $400


This example satisfies the current Amount in Controversy (AIC) requirement for a claim appeal filed in 2013 ($140 minimum AIC).

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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.

    1. If you have a Medicare Advantage Plan (Part C), please see the instructions under “I have a Medicare Advantage Plan.  How should I file a Request for Hearing?”  Generally if your Medicare Advantage (Part C) reconsideration was issued by the Part C QIC (Maximus Federal Services), you should file your request for ALJ hearing with the Part C QIC.
    2. If you are entitled to file a Part D appeal using expedited procedures, please see the instructions under “How and where do I file an Expedited Part D Request?”
    3. If you want an ALJ to review a decision from the Social Security Administration (SSA) regarding eligibility, entitlement or IRMAA please follow the directions provided to you by the SSA office that issued the decision. 
    4. If you are requesting an appeal related to Medicare Part A or Part B you should submit your request for hearing to the following address:

OMHA - Division of Central Operations

200 Public Sq. Suite 1260

Cleveland, OH 44114

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 Medicare Hearing By an Administrative Law Judge, which prompts you for all the necessary information.

      • If you are appealing a Qualified Independent Contractor (QIC) decision: CMS-20034A/B (PDF - 85KB);
      • If you are appealing a decision not made by a QIC: CMS-5011A/B (PDF - 85KB);
      • If you are appealing a QIC's dismissal of your request for reconsideration: HHS-725 (PDF - 437KB).

 

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 Beneficiary’s name, address and Medicare health insurance claim number

2. The name and address of the appellant, if you are not the Beneficiary

3. If appropriate, the name and address of your designated representative

4. The appeal number (Medicare Appeal Number or Medicare Case Identification Number) that appeared on your reconsideration decision

5. The dates of service being appealed (not applicable to entitlement/IRMAA)

6. The reasons you disagree with the reconsideration being appealed

7. A statement of any additional evidence to 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).

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

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

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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 – Division of Central Operations

Attn: Expedited Part D Appeal

200 Public Sq. Suite 1260

Cleveland, OH  44114

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

1. The name, address, telephone number, and Medicare health insurance claim number 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 Maximus

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 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.


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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.

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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 Administrative Law Judge (ALJ) to extend the deadline.  See "Extension Request to File a Request for an Administrative Law Judge Hearing (Form HHS 727)" (PDF - 26KB).  

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

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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:

  • Do not attach medical records or other documentary evidence to your request for Administrative Law Judge (ALJ) hearing.  Please limit your submission to the Request for ALJ hearing itself.  See the “When to Submit Your Evidence” section below for instructions on how and when to submit additional evidence.

 

  • Clearly list the Medicare Appeal Number for the Reconsideration you are appealing on your Request for ALJ hearing form.  This number will appear in the upper right-hand corner of the reconsideration decision letter in the following format, e.g. 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.   

 

WHEN TO SUBMIT YOUR EVIDENCE

  • When your request for hearing is assigned to an ALJ, we will send you a Notice of Assignment.  This notice will reflect the name and address of the ALJ assigned to your case.  If you would like to submit additional evidence related to your appeal, you should submit it after assignment directly to your assigned ALJ using the name and address referenced on this notice.   Alternatively, you may submit your evidence directly to the ALJ within ten calendar days of receipt of the Notice of Hearing.

 

  • Special instruction for providers or suppliers: if you are submitting new evidence to the ALJ that was not previously submitted at any prior level of appeal, the evidence must be accompanied by a statement explaining why the evidence was not previously submitted.  See 42 CFR § 405.1018.  The ALJ will then examine any new evidence to determine whether there is good cause to submit the evidence for the first time at the ALJ level.  42 CFR § 405.1028.

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.

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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 Administrative Law Judge (ALJ).  Due to the large volume of appeals currently in process, ALJ hearing capacity is limited.  When your appeal is assigned to an ALJ, the ALJ will then review your appeal. Typically the first step the ALJ will take will be to review your request to ensure all requirements are met.  After this review, the ALJ will schedule a hearing. 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, the ALJ may decide a case on-the-record, meaning that the ALJ will issue a decision without conducting a hearing. However, this only happens if the decision is favorable to the appellant or if all the parties waive their right to 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.

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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 that was filed with OMHA. 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 your 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.

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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 to a Medicare claim appeal that was filed with our office. 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.

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I just received a Notice of ALJ Hearing which says that my appeal is with an ALJ in Irvine/Cleveland/Arlington/Miami. 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.

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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.

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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.

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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.

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Has my Request for Hearing been received? 

OR 

What Field Office and ALJ has my case been assigned to? 

OR 

What is the status of my appeal? 

OR 

I submitted a Request For Hearing, 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 Administrative Law Judges 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 delay is posted on our website.

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I received an ALJ remand order that says the ALJ 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 ALJ’s order directs the prior appeal level to forward the case file or other information essential to resolving your appeal to our office so the ALJ can proceed with the case. There is nothing you need to do. You will be contacted when the appeal resumes.

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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 Appeals Process by Medicare Type. The time period for OMHA to issue decisions on cases at the ALJ-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 ALJs and their staff are processing hearing requests as quickly as possible.  OMHA is committed to providing the most timely decisions possible for all appeals at the ALJ-level. 

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

If you are appealing a Part A or Part B reconsideration issued by a Qualified Independent Contractor (QIC), you may have a right to escalate your request for hearing to the Medicare Appeals Council (MAC), 90 days after you file a complete request for hearing.  More information on escalating a request for hearing can be found at 42 C.F.R. sections 405.1104 and 405.1106(b).  When a request for hearing is escalated, the MAC may take any action in accordance with 42 C.F.R. section 405.1108(d), but is not required to conduct a hearing.

Escalating a request for hearing is a two-step process.  See In re General Medicine, P.C. (MAC Sep. 6, 2007).  To initiate the process, you must file a written request for escalation with OMHA.  If your request has been assigned to an Administrative Law Judge, please file your request with the Administrative Law Judge’s field office. Please clearly indicate your submission as an escalation request to help us process your request as quickly as possible.  Our field office addresses can be found at http://www.hhs.gov/omha/contacts/offices.html.

If your request has not been assigned to an Administrative Law Judge, please file your request for escalation with:

OMHA — Central Operations
Attn: Escalation Request Mailstop
200 Public Square, Suite 1260
Cleveland, OH 44114

After OMHA receives your initial request for escalation, you may receive a decision, dismissal, remand order, or a Notice on Escalation Request.  However, if you do not hear from us within 10 days (including 5 days for mailing time), you may consider your request escalated and proceed to seek MAC review of the escalated request.  The request for MAC review must:

  1. Contain the required content for a request for review of an escalated case set forth in 42 C.F.R. section 405.1112;
  2. Be sent to both the MAC and the Administrative Law Judge’s OMHA office (or OMHA Central Operations if you sent your request for escalation there); and
  3. Be copied to the other parties to the appeal (for example, the parties who received a copy of the Notice of Reconsideration).

Please note that if you do not request MAC review of an escalated request, the case will remain pending with OMHA and the Administrative Law Judge adjudication process will continue.

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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 ALJ. You can find this form by going to the www.hhs.gov/omha home page, then by following the “Forms” link on the left side of the screen. The link to the form is located under the “Pre-Hearing Forms Needed by OMHA” section.

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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.

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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.

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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.

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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.

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I disagree with the ALJ’s Decision. What do I do next? 

OR 

I want to appeal the ALJ’s decision. What do I do next? 

Please refer to the Notice of Decision document, which was issued with the ALJ’s decision. Generally, if you disagree with the ALJ’s decision you must submit a written request for review with the Medicare Appeals Council within 60 calendar days of receiving the ALJ decision 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

However, for more specific instructions, please carefully review the Notice of Decision document.

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

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I received a favorable ALJ 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.

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