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 pass through Level 1 and Level 2 of the appeals process. For more information, see "The Appeals Process."
This section is broken into the following five parts:
- 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)
Requirements for an Appeal
Before you can request a hearing from OMHA, ensure the following:
- Your written request is within 60 days of receiving the Level 2 appeals decision. If you miss the 60-day deadline, you must explain why your request is late and ask the OMHA adjudicator to extend the deadline. See "Request for Extension of Time to File Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal (Form OMHA-103)." - PDF If the adjudicator finds good cause for missing the deadline, the time period for filing the hearing request may be extended.
The claim(s) value in dispute must meet the threshold for obtaining an ALJ hearing. This is called the “amount in controversy.” The amount in controversy 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 of the claims in the same request for ALJ hearing, or in multiple requests for hearing filed with the same request for 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 OMHA adjudicator determines that the claims involve similar or related services.
How to Submit a Request for an Appeal
You can use the forms below to request an ALJ hearing:
- If you are appealing a Qualified Independent Contractor (QIC) or Independent Review Entity (IRE) decision or dismissal: OMHA-100;
For appeals involving multiple beneficiaries or enrollees associated with the same reconsideration or dismissal, use the Multiple Claim Attachment: OMHA-100A.
You may instead submit a written request with the information listed below. Note that if any of the described information is missing from your request for an ALJ hearing, it can cause delays in the processing of your appeal.
- The beneficiary's name, address, and Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier);
- The beneficiary's telephone number if the beneficiary is the appealing party and is not represented;
- The name, telephone number, and address of the appellant, when the appellant is not the beneficiary;
- The name, telephone number, and address of the designated representative, if any;
- The document control number assigned by the QIC or QIO, if any;
- The dates of service being appealed;
- The reasons you disagree with the reconsideration or other determination being appealed; and
- A statement of any additional evidence to be submitted, the date it will be submitted and why it was not submitted previously.
- The name, address, telephone number, and Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier) of the enrollee;
- The name, address, and telephone number of the appointed representative, if any;
- The Medicare appeal number, if any, assigned to the reconsideration or dismissal being appealed;
- The prescription drug in dispute;
- The plan name;
- The reasons the enrollee disagrees with the reconsideration or dismissal being appealed;
- A statement of any additional evidence to be submitted and the date it will be submitted; and
- A statement that the enrollee is requesting an expedited hearing, if applicable.
For appeals related to Medicare Part A or Part B, you may submit your appeal request online. Visit the OMHA e-Appeal Portal (Portal) and register for an account. Through the Portal, you may directly upload Form OMHA-100 or use the guided tutorial to create and upload your request.
To appeal by mail, send your written request for ALJ hearing to the office specified in the reconsideration determination. In most instances, the reconsideration will direct you to mail your written request to:
OMHA Central Operations
1001 Lakeside Ave., Suite 930
Cleveland, OH 44114-1158
However, you should always defer to the address specified in the reconsideration or reconsideration determination. Failure to do so will delay the processing of your request.
Note: If you are a beneficiary filing an appeal, please include the following as part of the address:
Attn: Beneficiary Mail Stop
For more information on beneficiary appeals, see Medicare Beneficiary and Enrollee Appeals and Assistance.
Whether you file by mail or online, you must also send a copy of the request to the parties who were sent a copy of the Level 2 (reconsideration) decision or dismissal.
For more information, read our tips for filing a request for an ALJ hearing.
Setting Up Your ALJ Hearing
Finding Out How, When and Where the Hearing Will be Held
The ALJ sets the time and place for your hearing.
You will be sent a Notice of Hearing with the date, time, and location of your hearing at least twenty (20) days before the hearing. A hearing will generally be held by telephone, unless you are an unrepresented beneficiary or enrollee. However, an in-person hearing may be held if the ALJ determines the circumstances of the appeal warrant an in-person hearing. An appearance by video-teleconference (VTC) may also be arranged for an unrepresented beneficiary, or if the ALJ determined that VTC is necessary to examine the facts or issues involved in the appeal. Your hearing may take longer to schedule if the ALJ needs to schedule a medical or non-medical expert to testify.
There may also be cases in which the issues are decided solely on the documentary evidence and without an oral hearing. This is called an on-the-record decision.
There are several field offices nationwide and hundreds of VTC sites where hearings may be held. This extensive network assists OMHA in providing you with ready access to hearings, even in remote locations. It also reduces the distance that you may need to travel for your hearing.
Responding to the Hearing Request
Once you receive the Notice of Hearing, fill out "Response to Notice of Hearing (Form OMHA-102)" - PDF and return it to the ALJ listed on the Notice of Hearing within 5 days of receiving it.
Requesting an In-person Hearing
Information on Video-Teleconferencing (VTC)
Office of Medicare Hearings and Appeals (OMHA) hearings often use video-teleconferencing technology or "VTC." VTC hearings utilize video cameras and televisions so you and the ALJ can see and hear one another. This technology allows you to have a hearing without having to travel to an OMHA field office. Often a VTC hearing can be scheduled faster than an in-person hearing and that means less waiting time for you. Also, a VTC hearing location may be closer to your home and that might make it easier for you to have witnesses or other people accompany you.
The VTC occurs in a private room and is completely confidential. A technician will make sure the equipment is working, but will not be present during the hearing and cannot hear your case. No one except your representative, or someone else you might choose, witnesses the hearing, except for select individuals that the ALJ considers necessary and proper. You will be able to see, hear and talk to the ALJ at the hearing. Transmission of the hearing is secure, and your privacy is protected. While all hearings are recorded, only audio recordings are made. No video recordings are made.
If we are using VTC equipment in your area, we will contact you to schedule your VTC hearing for a convenient time. We realize that not everyone is familiar with how VTC works. The OMHA field office staff have a list of VTC sites near your home and can assist you in selecting a site. In addition, they can answer any questions you may have concerning VTC hearings.
The ALJ will consider any concerns you may have expressed regarding your VTC hearing and the circumstances of the appeal when setting the time and place of your hearing. Once the time and place for your hearing are set, you will have an opportunity to object to either the time or place established for your hearing. The ALJ will reschedule the hearing if you have good cause for changing the time or place. Again, if you have any questions or want more information, please contact your OMHA field office.