Third-Level Appeal

Hearing by an Administrative Law Judge

If at least $110 (2007 threshold)  remains in controversy following the QIC’s decision, a party to the reconsideration may request an Administrative Law Judge (ALJ) hearing within 60 days of receipt of the reconsideration.

Office of Medicare Hearings and Appeals (OMHA)
OMHA administers nationwide hearings for the Medicare program. The ALJs within OMHA conduct impartial hearings and issue decisions on behalf of the Secretary on claims determination appeals involving Parts A, B, C and D of Medicare, and on Medicare entitlement and eligibility appeals.

RESOURCE PAGE: What You Need To Know To Request a Medicare Hearing Before an Administrative Law Judge

Note: The amount in controversy required to request an ALJ hearing is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.


Requesting a Hearing

  • Request for ALJ hearing is due 60 days from date of receipt of the QIC’s reconsideration notice.
  • ALJ hearings are generally held by video-teleconference (VTC) or by telephone.
  • If an appellant does not want a VTC or telephone hearing, an in-person hearing may be requested. An appellant must demonstrate good cause for requesting an in-person hearing. The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis.
  • Appellants may also ask the ALJ to make a decision without a hearing (on-the-record).
  • Hearing preparation procedures are set by the ALJ. 
  • Refer to the reconsideration decision letter for details regarding the procedures for requesting an ALJ hearing.


Supporting Documentation

  • Appellants must send notice of the ALJ hearing request to all parties to the QIC reconsideration and verify this on the hearing request form or in the written request. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and all parties to the hearing.
  • Case file prepared by the QIC & forwarded to the Office of Medicare Hearing & Appeals (OMHA).
  • No additional documentation from appellant regarding the case unless requested.


Decision Notification

  • ALJ is not bound by Local Coverage Determination (LCDs), but LCDS will be given substantial deference.
  • The ALJ will generally issue a decision within 90 days of receipt of the hearing request. This timeframe may be extended for a variety of reasons including, but not limited to:
    • the case being escalated from the reconsideration level
    • the submission of additional evidence not included with the hearing request
    • the request for an in-person hearing
    • the appellant’s failure to send notice of the hearing request to other parties
    • the initiation of discovery if CMS is a party
  • If the ALJ does not issue a decision within the applicable timeframe, an appellant may ask the ALJ to escalate the case to the Appeals Council level.
  • The ALJ decision includes details regarding the procedures to follow when filing a request for Appeals Council Review.


Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) enacted numerous contracting reforms that can impact the claims audit and appeals processes. Check often for new developments: Medicare Contracting Reform Updates

 

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