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 "The Appeals Process."
How and When You Will be Notified of the Adjudicator's Determination on Your Appeal
- You will be notified of the adjudicator's decision, remand, or dismissal by U.S. mail.
- Please see our Current Workload page for information on processing times.
- In some instances, if the OMHA adjudicator does not adjudicate the appeal within the 90 day period, you may request escalation of your appeal to the Medicare Appeals Council (Council).
When an OMHA Adjudicator Issues a Decision Favorable to You
If the OMHA adjudicator 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 OMHA adjudicator who is responsible to pay the claim according to the OMHA decision and applicable Medicare payment policies. Therefore, any questions you may have regarding Medicare payment following a favorable OMHA decision should be directed to the Medicare contractor and not OMHA.
When an OMHA Adjudicator Issues a Decision that is Not Favorable to You
If you are not satisfied with the OMHA decision or dismissal, you may request that the Medicare Appeals Council (Council) review your case. Your request for the Council to review your claim must be made within 60 days of the date you receive the decision or dismissal. 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 Council review of an OMHA adjudicator's remand, but a party or CMS or one of its contractors may request the Chief ALJ or designee to review an adjudicator's remand within 30 calendar days of receiving a notice of remand. See 42 CFR § 405.1056(g) for more information.
There is no right to Council or Chief ALJ review of an OMHA adjudicator's affirmation of a QIC's dismissal of a request for reconsideration.