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Coverage and Claims Appeals

OMHA is in charge of Level 3 of the coverage and claims appeals process.  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."

At Level 3 of the appeals process, you may have a hearing before an Administrative Law Judge (ALJ).  This gives you the opportunity to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a new and impartial decision in accordance with the applicable law.

In some instances, an OMHA ALJ may decide a case on-the-record if all parties waive their rights to an oral hearing or when the documentary evidence supports a finding fully favorable to the appellant.

Medicare Beneficiary and Medicare Advantage Part C Plan Enrollee or Part D Plan Enrollee Appeals and Assistance

To help ensure Medicare Beneficiary and Enrollee appeals are adjudicated as quickly as possible, OMHA designates appeals filed by Beneficiaries and Enrollees as priority appeals, with some exceptions.Learn more about appeals and assistance.

In this section of the web site, you will find the following:

Topic Description
Request an ALJ Hearing
  • Requirements for an Appeal
  • How to Submit a Request for an appeal
  • Setting Up Your ALJ Hearing
  • Requesting an In-person Hearing
  • Information on Video-Teleconferencing (VTC)
Your ALJ Hearing
  • What to Expect from the ALJ During the Hearing
  • Canceling an ALJ Hearing
Documents for Your Hearing
  • Viewing your Current Case File
  • Submitting New Evidence
  • How OMHA Manages your Documents
After the ALJ Decision
  • How and When You Will be Notified of the Hearing Decision
  • When the ALJ Issues a Decision Favorable to You
  • When the ALJ Issues a Decision that is Not Favorable to You
Tips for a Timely Review
  • Things you can do to assist the processing of your request for hearing


Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on August 10, 2016