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Level 4 Appeals

If you are not satisfied with your Level 3 decision or dismissal, you may request that the Medicare Appeals Council (MAC) review the ALJ's decision.

The Medicare Appeals Council (MAC):

  • Conducts the Level 4 appeal, and is
  • Part of the Departmental Appeals Board of the Department of Health and Human Services (HHS), and is
  • Independent of OMHA and its ALJs.

Note:  A party does not have the right to seek MAC review of an ALJ's remand to a QIC or an ALJ's affirmation of a QIC's dismissal of a request for reconsideration.

A written request is required to obtain a MAC review.  You may send a letter.  For more information, see the MAC website.

Required Information

Your request for review should include certain case identifying information, such as the:

  • Beneficiary's name;
  • Name of the health services provider;
  • Date and type of service;
  • Medicare contractor or managed care organization that issued the initial determination in your case;
  • Health Insurance Claim Number (HICN);
  • OMHA appeal number;
  • Date of the Administrative Law Judge (ALJ) decision or dismissal;
  • An appointment of representative, such as CMS Form 1696 (PDF, 66.4 KB) (if applicable);
  • Any additional evidence, clearly marked as new or duplicate; and
  • Proof that you provided copies of your request to all other parties.

Submitting your request

You may mail your request to:

Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, SW, Room G-644
Washington DC 20201

You may also fax your request for review to (202) 565-0227.

Be sure to send a copy of your request to the organization that originally denied your claim (e.g., your HMO, health care provider, etc.).

Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.

Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on December 12, 2014