A hearing before an Administrative Law Judge (ALJ) allows you to present your appeal to a new person who will review the facts of your appeal independently and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, or in some cases, in person. You can also ask the ALJ to make a decision without a hearing, and the ALJ may also issue a decision without holding a hearing if evidence in the hearing record supports a decision that's fully in your favor.
To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2015 and 2016, the required minimum amount is $150. The ALJ will decide if your case meets the minimum dollar amount. You may be able to combine claims to meet the minimum dollar amount.
If you have Original Medicare, follow the directions on the "Medicare Reconsideration Notice" you got from the QIC in level 2 to request a hearing before an ALJ. You must send your request to the appropriate Office of Medicare Hearings and Appeals (OMHA) Central Operations. The address is listed in the QIC's reconsideration notice.
If you have Original Medicare, a Medicare Advantage plan, other Medicare health plan, or a Medicare Prescription Drug Plan, you can file a request for a hearing in one of these ways:
- Fill out a "Request for Medicare Hearing by an Administrative Law Judge" form.
- Submit a written request to the OMHA office that will handle your ALJ hearing that includes:
- Your name, address, and Medicare number. If you've appointed a representative, include your representative's name and address.
- The appeal number included on the QIC reconsideration notice, if any.
- The dates of service for the items or services you're appealing. See your MSN or reconsideration notice for this information.
- An explanation of why you disagree with the reconsideration decision being appealed.
- Any information that may help your case. If you can't include this information with your request, include a statement explaining what you plan to submit and when you'll submit it.
If you want your doctor or other prescriber (for prescription drug appeals) to request this level of appeal on your behalf, you’ll need to submit an “Appointment of Representative” form.
In most cases, the ALJ will send you a written decision within 90 days of getting your request. If the ALJ doesn't issue a timely decision, you may ask the ALJ to move your case to the next level of appeal.
If you disagree with the ALJ's decision in level 3, you have 60 days after you get the ALJ's decision to request a review by the Medicare Appeals Council (Appeals Council).