Appeals Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)

You may request a decision by OMHA, based on a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, a review of the appeal record by an ALJ or attorney adjudicator.

A hearing before a ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, but can be held in person if the ALJ finds that you have a good reason. You can ask OMHA to make a decision without holding a hearing (based only on the information that's in your appeal record). The ALJ or attorney adjudicator 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 a hearing or review by OMHA, the amount of your case must meet a minimum dollar amount. For 2019, the required minimum amount is $160 ($170 in 2020). The "Reconsidered Determination" may include a statement that tells you if your case is estimated to meet the minimum dollar amount. However, it's up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.

 

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 OMHA Central Operations. The address is listed in the QIC's reconsideration notice.

You or your representative can file a request for a hearing in one of these ways:

  1. Fill out a "Request for Medicare Hearing by an Administrative Law Judge" form [PDF, 96.6 KB].
  2. Submit a written request, which must include:
    • Your name, address, phone number, and Medicare Number. If you've appointed a representative, include the name, address, and phone number of your representative.
    • The appeal number assigned by IRE, if any.
    • The dates of service for the items or services you're appealing. 
    • An explanation of why you disagree with the IRE's 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.

You can find more information about the ALJ hearing process at the Office of Medicare Hearings and Appeals website, or 

call us at 1-800-MEDICARE.

Can I request a review of my case without a hearing?

Yes. To request that OMHA make a decision without a hearing based only on the information that's in your appeal record, submit the information required for an ALJ hearing request and one of these:

Even if you waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case who were sent a notice of hearing (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.

If you have asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and issue a decision.

If OMHA decides in your favor, the plan has the right to appeal this decision by asking the Medicare Appeals Council (Appeals Council) for a review.

If OHMA doesn't issue a timely decision, you may ask OMHA to move your case to the next level of appeal.

If you disagree with the OMHA's decision in level 3, you have 60 days after you get the decision to request a review by the Medicare Appeals Council (Appeals Council), which is level 4.