Hearing by an Administrative Law Judge (ALJ)

If the Part C Independent Review Entity (IRE) issues an adverse reconsideration decision, any party to the reconsideration (except the Medicare Advantage organization) may appeal the IRE's decision by requesting an Administrative Law Judge (ALJ) hearing.  The Office of Medicare Hearings and Appeals (OMHA) is responsible for administering ALJ hearings and attorney adjudicator reviews.  For more information on OMHA and how to contact them, click on the link to "The Office of Medicare Hearings and Appeals" in the "Related Links" section below.

How to Request a Hearing by an ALJ

In order to request a hearing by an ALJ, the amount remaining in controversy must meet the threshold requirement. This amount may change each year. For calendar year 2024, the amount in controversy is $180.  To view the Amount in Controversy Federal Register notice for calendar year 2024, see the "Related Links" section below.

The appeal request must be made in writing and be filed within 60 calendar days from the date of receipt of the IRE's reconsideration decision notice. A written request may be made using the form "OMHA-100". 

A link to all OMHA forms can be found on the OMHA forms webpage:

https://www.hhs.gov/about/agencies/omha/filing-an-appeal/forms/index.html

If the ALJ’s decision is unfavorable, the decision will contain information needed to file a request for review by the Medicare Appeals Council. Use the left navigation menu on this page for links to detailed information about reviews by the Medicare Appeals Council or any other level of appeal.

Attorney Adjudicator Review

If an appellant doesn’t want to attend a hearing, they can fill out the “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104) and submit it with a request for a hearing. An ALJ or attorney adjudicator may decide a case on the record and without an ALJ conducting a hearing if all the parties elect to not appear at a hearing. It’s possible, however, that an ALJ may determine that it’s necessary to hold a hearing, even if all the parties have waived the right to appear. In those cases, the ALJ will give the parties the opportunity to appear but may hold the hearing even if none of the parties decide to appear.

For more information about requesting a hearing with an ALJ or a review of the administrative record by an attorney adjudicator, or information about how the amount in controversy is computed, see section 70 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the "Downloads" section below.