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Forms Needed for Your Level 3 Appeal

Below is a list of Level 3 forms only that may pertain to your request for a hearing by an Administrative Law Judge.  

Request or Waive an Administrative Law Judge Hearing with OMHA

Form Description
Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal
Form OMHA-100
This form is used to request review of a reconsideration determination or dismissal issued by a Qualified Independent Contractor (QIC) or Independent Review Entity (IRE).
Remember, the remaining amount in controversy must meet the current minimum for an ALJ review.
Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal – Multiple Claim Attachment
Form OMHA-100A
This form is used as an attachment to form OMHA‑100 to identify multiple beneficiaries or enrollees associated with a single request for an Administrative Law Judge (ALJ) hearing or a review of dismissal.
Request for Extension of Time to File a Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal
Form OMHA-103
This form is used to request an extension to submit your request for an Administrative Law Judge (ALJ) hearing or review of a dismissal with the Office of Medicare Hearings and Appeals (OMHA) beyond the normal 60 calendar days following receipt of a reconsideration or dismissal. An ALJ or attorney adjudicator has the discretion to accept your request based on your good cause explanation as to why you are unable to submit your request for hearing or review of a dismissal within the 60 days, or to determine that you did not have good cause for late filing of a request for review of a dismissal. However, only an ALJ may determine that you did not have good cause for late filing of a request for hearing.
Withdrawal of Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal
Form OMHA-119
This form is used to withdraw your request for an Administrative Law Judge (ALJ) hearing or review of a dismissal before the Office of Medicare Hearings and Appeals (OMHA). If you file this form, your appeal will be dismissed by the OMHA adjudicator if no other party has filed a valid request for an ALJ hearing or review of a dismissal. Your request will not be honored if the ALJ has already issued a decision or other dispositive order.
Waiver of Right to an Administrative Law Judge (ALJ) Hearing
Form OMHA-104
This form is used to waive your right to have an oral hearing before the Administrative Law Judge (ALJ). If you and all of the other parties who would receive a notice of hearing waive this right, your case will be decided on the record without an oral hearing.
Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ) Hearing
Form OMHA-114
This form is used to withdraw your prior decision to waive your right to have a hearing before the Administrative Law Judge (ALJ). Your request may be honored only if the ALJ has not yet issued a decision. The ALJ may extend the decision-making time frame beyond the normal period in order to schedule and hold the hearing.

Pre-Hearing Forms Needed by OMHA

Form Description
Response to Notice of Hearing
Form OMHA-102
This form is used to indicate whether you intend to be present at the time and place of a scheduled hearing. You need to complete sections 2 through 8 and return the form to the assigned Administrative Law Judge (ALJ) within 5 calendar days of receipt (2 calendar days for expedited Part D hearings).
Identity Verification
Form HHS-733
This form is used by the Office of Medicare Hearings and Appeals when it needs to confirm your identity.
Filing of New Evidence
Form OMHA-115
This form is used to submit additional evidence to be considered by the assigned OMHA adjudicator.
Appointment of Representative
Form CMS-1696
This form is used to appoint a representative to assist with an appeal.  An appointed representative may be a family member, friend, lawyer or provider/supplier.

Notice of Intent to Participate in Proceedings on a Request for an Administrative Law Judge (ALJ) Hearing or to be a Party to an ALJ Hearing
Form OMHA-105

This form is for CMS, a CMS contractor, or a Part D Plan Sponsor that wishes to elect (in Medicare Part A and B appeals) or request (in Medicare Part D appeals) to be a participant in the proceedings on a request for an Administrative Law Judge (ALJ) hearing. CMS or a CMS contractor may alternatively use this form to elect to be a party to an ALJ hearing in a Medicare Part A or Part B appeal, if one is scheduled and the request for hearing was not filed by an unrepresented beneficiary.

Records, Record Change, and Information Requests

Form Description
Request for Copy of the Record(s) in the Case File
Form HHS-719
This form is used by you or your authorized or appointed representative to request a copy of all or part of your record.
Request for Copy of the Record(s): Third-Party with the Individual Appellant's Consent 
Form HHS-720
This form is used by a third party to request, with your consent, a copy of all or part of your record.
Individual Appellant's Consent to Third-Party for Copies of the Individual Appellant's Record(s)
Form HHS-721
This form is used by you to consent to a request by a third party to receive a copy of all or part of your record.
Request to Correct, Amend, or Delete a Record(s)
Form HHS-724
This form is used to request a correction, amendment, or deletion of a record. After you submit this form, it is up to the Administrative Law Judge (ALJ) to determine whether the record should be corrected, amended, or deleted.
Payment Information Report
Form HHS-734
This form is used by the Office of Medicare Hearings and Appeals to collect your bank information in order to make the direct deposit into your account. This is not payment of Medicare services.

Request for Substitution Upon Death of Beneficiary

Form Description
Request for Substitution of Party Upon Death of Beneficiary or Enrollee
Form OMHA-106

 

This form allows a substitute party to enter the proceedings if the Medicare beneficiary or enrollee died after a hearing was requested but before a decision, dismissal, or remand was issued. The substitute party can be either someone with legal authority to act on behalf of the beneficiary or enrollee or, if no such individual exists with a genuine financial interest, it can be the provider or supplier who furnished items or services.

 

Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on March 24, 2017