Tips for Filing a Request for ALJ Hearing or Review of Dismissal
Where to File
If you are requesting an Administrative Law Judge (ALJ) hearing or a review of a reconsideration dismissal related to a Medicare Part A, Part B, Part D, or QIO case, please submit your request for hearing to:
OMHA Central Operations
1001 Lakeside Ave., Suite 930
Cleveland, OH 44114-1158
The address above is effective December 13, 2019.
For all other appeal types (for example, Medicare Part C, and Income Related Monthly Adjustment Amount (IRMAA) and Entitlement from the Social Security Administration), please review the instructions provided in your reconsideration decision to determine the filing location.
If applicable, please include one of the following mail stops when addressing your request for hearing or review of a dismissal submission:
|Attn: Beneficiary Mail Stop||Use this mail stop if you are a beneficiary, enrollee, or a representative appealing on behalf of a beneficiary or enrollee. Although not mandatory, you may use form OMHA-100.|
|Attn: Expedited Part D Mail Stop||Use this mail stop if you are an enrollee or a representative appealing on behalf of an enrollee submitting a request for an expedited Part D appeal by mail. Although not mandatory, you may use form OMHA-100.|
|Attn: Withdrawal Mail Stop||Only use if you are seeking to withdraw a request for hearing or review of a dismissal you previously submitted (form OMHA-119) that has not yet been assigned to an adjudicator.|
|Attn: Waiver Mail Stop||Use this mail stop if you are waiving your right to an oral hearing (form OMHA-104) or you are withdrawing your waiver of the right to an oral hearing (form OMHA-114) and your request for hearing has not yet been assigned to an adjudicator.|
|Attn: New Evidence Mail Stop||Use this mail stop if you have new evidence to submit (form OMHA-115) and your request for hearing or review of a dismissal has not yet been assigned to an adjudicator.|
|Attn: CMS and CMS Contractor Elections||Use this mail stop only if you are a CMS, a CMS contractor, or a Part D Plan Sponsor that wishes to elect or request to be a party or participant in the ALJ hearing (from OMHA-104), as appropriate), and the request for hearing has not yet been assigned to an adjudicator.|
|Attn: Substitution of Party Mail Stop||Use this mail stop to request to enter proceedings before OMHA if the Medicare beneficiary or enrollee died after a hearing was requested but before a decision, dismissal, or remand was issued (form OMHA-106).|
|Attn: Escalation Mail Stop||Use this mail stop if you are seeking to escalate to the Medicare Appeals Council (form OMHA-384) a request for hearing in a Part A or Part B case that has been pending longer than 90 calendar days (or 180 days, if you escalated the case to OMHA), and your request for hearing has not yet been assigned to an adjudicator. For more information, see Escalation.|
|Attn: Remand Review||Use this mail stop if you are a party to an appeal, CMS, a CMS contractor, or a Part D plan sponsor, and you want to request the OMHA Chief Administrative Law Judge, or designee, review the remand (form OMHA-107)|
You must send a copy of your request for hearing or review to the other parties who were sent a copy of the reconsideration decision or dismissal. These parties typically include the beneficiary and the provider/supplier who furnished the items or services. You do not need to send a copy of your request for hearing to the QIC that issued the reconsideration decision or dismissal. Evidence that a copy of the request for hearing or review was sent to the other parties includes: (1) certification in section 10 of form OMHA-100; (2) an indication, such as a copy or “cc” line, on the request that a copy is being sent; (3) an affidavit or certification of service; or (4) a mailing or shipping receipt.
Please send your request for hearing or review via a tracked mail service such as UPS or FedEx. Tracked mail service will provide you with delivery confirmation as well as important delivery details.
What Information to Include
Although not required, you may use form OMHA-100 when filing a request for hearing or review. Form OMHA-100 can be found on the Forms page.
If you do not complete form OMHA-100, please ensure that your request for hearing or review includes all of the following information:
- Beneficiary’s name, address, and Medicare number (Health Insurance Claim Number or Medicare Beneficiary Identifier)
- Beneficiary’s telephone number, if the beneficiary is the appealing party and not represented
- Appellant’s name, address, and telephone number, when the appellant is not the beneficiary
- Representative’s name, address, and telephone number (if applicable)
- Medicare Appeal Number that is assigned to your reconsideration decision or dismissal by the QIC
- Date(s) of service at issue (if applicable)
- Reason(s) you disagree with the QIC’s reconsideration or other determination being appealed
If you are appealing a statistical sample and/or extrapolation, you must include the information outlined above for each sample claim that you wish to appeal, and assert the reasons you disagree with how the statistical sample and/or extrapolation was conducted.
Please prominently list the Medicare Appeal Number on your request for hearing or review. It is located in the upper right hand corner of the reconsideration decision or dismissal you are appealing. If using form OMHA-100, the Medicare Appeal Number should be listed in the box titled “Reconsideration (Medicare Appeal or Case) Number.” You should submit only one request for hearing or review for each Medicare Appeal Number you wish to appeal.
Please include the beneficiary’s full Medicare number (Health Insurance Claim Number or Medicare Beneficiary Identifier) on your request for hearing or review.
Filing Time Frame
If you file a request for hearing or review more than 60 calendar days from the date you received your reconsideration decision or dismissal, please include a written explanation of why your request is late.
If you are appealing a statistical sample and/or extrapolation and the sample claims were not all addressed in a single reconsideration, you must file the request for hearing or review for all sample claims that you wish to appeal within 60 calendar days of the date you receive the last reconsideration for the sample claims.
If the reconsideration you are appealing involves more than one beneficiary, please input “MULTIPLE” under “Beneficiary or Enrollee Name” on the form OMHA-100 and provide a full list of each beneficiary’s information as a separate attachment using the Multiple Claim Attachment form OMHA-100A, available on the Forms page.
Grouping Multiple Requests for Hearing
If you would like two or more requests for hearing to be grouped together for a single hearing by the same adjudicator, please prepare a separate request for hearing for each Medicare Appeal Number in the group. Submit the requests for hearing to OMHA in the same package with a cover letter expressly stating that you want them to be grouped for a single hearing. OMHA will only consider grouping requests for hearing contained in the same shipment, involving the same provider/supplier and sharing the same issues.
Aggregating Claims to Meet the Amount in Controversy
The value of the claim(s) in dispute must meet the minimum amount in controversy threshold for obtaining an ALJ hearing. See “How is the Amount in Controversy Calculated?” for information on the current amount in controversy threshold. If you would like to aggregate claims to meet the amount in controversy threshold, you may request aggregation of claims appealed in the same request for hearing, or in multiple requests for hearing filed with the same request for aggregation. Submit the request(s) for hearing to OMHA in the same package with a cover letter expressly stating that you want them to be aggregated. Please note that requests to aggregate claims are subject to the requirements of 42 C.F.R. § 405.1006(e) and (f).
Withdrawing a Request for Hearing or Review of a Dismissal
If you would like to withdraw your request for hearing or review of a dismissal and an adjudicator has not yet been assigned to your case, mail your written withdrawal request to Central Operations with the following “Attn: Withdrawal Mail Stop.” If an adjudicator has been assigned to your case, submit your written withdrawal request directly to the adjudicator. To find out whether an adjudicator has been assigned to your case, see Appeal Status Lookup.