Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA)

Any party that is dissatisfied with the Qualified Independent Contractor’s (QIC's) reconsideration decision may request a hearing before an Administrative Law Judge (ALJ) with the Office of Medicare Hearings and Appeals (OMHA). If the adjudication period for the QIC to complete its reconsideration has elapsed and the QIC is unable to complete the reconsideration by the deadline (with allowance for extensions), the appellant party has the opportunity to escalate the appeal to an ALJ or attorney adjudicator.

Requesting a Hearing by an ALJ

A request for an ALJ hearing must be filed with OMHA within 60 days of receipt of the reconsideration decision. The date of receipt of the reconsideration decision is presumed to be 5 days after the date of the decision notice, unless there is evidence to the contrary. Appellants must send notice of the ALJ hearing request to all other parties who were sent a copy of the QIC’s reconsideration, and include evidence of notification with the request for hearing or review (for details, see 42 CFR 405.1014).

In order to request a hearing by an ALJ, the amount remaining in controversy must meet the threshold requirement. This amount is recalculated each year and may change. 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. Information on calculating the amount in controversy is further down on this page. The reconsideration decision letter from the QIC provides full details on how to request an ALJ hearing. The request must be made in writing and can be filed using the form “OMHA-100” (see below). An appeal may be filed by mail or electronically via the OMHA e-Appeal Portal at https://hhs-ecape-portal.entellitrak.com.” If mailing an appeal and the form is not used, the request must contain all of the following information:

• The name, address, and Medicare number of the beneficiary whose claim is being appealed, and the beneficiary's telephone number if the beneficiary is the appealing party and not represented
• The name, address, and telephone number, of the appellant, when the appellant is not the beneficiary
• The name, address, and telephone number, of the authorized or appointed representative, if any.
• The Medicare appeal number or document control number, if any, assigned to the QIC reconsideration or dismissal notice being appealed
• The dates of service of the claim(s) being appealed
• The reasons the appellant disagrees with the QIC's reconsideration or other determination being appealed 

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

Appearance at an ALJ Hearing

ALJ hearings are held by telephone, unless the ALJ finds good cause for an appearance by other means such as video teleconference (VTC) or in person. An unrepresented beneficiary who filed a request for hearing may have the hearing conducted by VTC if the ALJ finds that VTC technology is available, or by telephone if more convenient for the beneficiary, unless the ALJ find good cause for an in person appearance. Hearing preparation procedures are set by the ALJ. CMS or its contractors may become a party to, or participate in, an ALJ hearing after notifying all parties to the hearing.

Attorney Adjudicator Review

If an appellant does not wish to have a hearing conducted, but does wish to have the case decided with only a review of the administrative record, appellants may waive their right to have an oral hearing by filling out the “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104) and submitting it with your request for hearing by OMHA. 

Calculating the Amount in Controversy

The amount remaining in controversy is computed as the actual amount charged the individual for the items and services in the disputed claim, reduced by:

• Any Medicare payments already made or awarded for the items or services; and
• Any deductible and/or coinsurance amounts that may be collected for the items or services.

Example:

                Amount charged:                     $500

                Medicare payment made:        $  0

                Subtotal balance:                    $500

                Copayment:                              -$100

                Balance:                                     $400      

                Amount in controversy:          $400

See the Federal Register notice on the 2024 amount in controversy in the "Related Links" section below.

OMHA Review of a Dismissal of a Reconsideration Request

Parties to the reconsideration have the right to request review of a QIC dismissal, if the amount in controversy and other filing requirements are met. The request for review must be filed in writing with OMHA within 60 days after the date of receipt of the QIC’s dismissal. The date of receipt of the reconsideration decision is presumed to be 5 days after the date on the dismissal, unless evidence exists to the contrary.

NOTE: A party that requests OMHA to review a QIC's review of a Medicare Administrative Contractor's dismissal of a redetermination request will not receive OMHA review. The QIC's decision is binding and not subject to further review, per 42 CFR 405.974(b)(3).

OMHA Review of Escalation of a Reconsideration Request

If the adjudication period for the QIC to complete its reconsideration has elapsed (with exceptions for extensions for additional evidence submissions and late filing), the QIC must send a notice to advise the parties that it cannot complete the reconsideration by the deadline, and advise the appellant of the right to request escalation of the appeal to OMHA. If the appellant party chooses to escalate the appeal to OMHA, a written request must be filed with the QIC in accordance with instructions on the escalation request notice. OMHA's 180 calendar day period to issue a final decision, dismissal order, or remand order begins on the date the request for escalation is received by OMHA.

Dismissal of a Request for Review or Hearing

A request for hearing before an ALJ or a request for review of a QIC dismissal may be dismissed by OMHA under either of 2 circumstances:

1. The appellant withdraws the request; or
2. For cause.

Information on OMHA dismissals can be found at 42 CFR 405.1052. OMHA mails or otherwise transmits a written notice of the dismissal to all parties who were sent a copy of the request for hearing or review.

Parties to OMHA’s dismissal of a request for hearing have 2 options if they disagree with the dismissal:

1. Request review of the dismissal by the Medicare Appeals Council (the Council)
2. Request that OMHA vacate its dismissal

OMHA Decision Notification

When a request for an ALJ hearing is filed after a QIC has issued a reconsideration, an ALJ or attorney adjudicator issues a decision, dismissal order, or remand to the QIC, as appropriate, no later than the end of the 90 calendar day period beginning on the date the request for hearing is received by the office specified in the QIC's notice of reconsideration, unless the 90 calendar day period has been extended. This timeframe may be extended for a variety of reasons including, but not limited to:

• The submission of additional evidence not included with the hearing request
• The request for an in-person hearing
• The appellant's failure to send a notice of the hearing request to other parties
• The initiation of discovery when CMS or its contractor is a party

For escalated requests for review of a QIC reconsideration, an ALJ or attorney adjudicator generally issues a decision, dismissal order, or remand to the QIC, as appropriate, no later than the end of the 180 calendar day period beginning on the date that the request for escalation is received by OMHA. If OMHA does not issue a decision, a dismissal, or remand order within the adjudication period specified (with exceptions for timeframe extensions noted), the appellant may send a request to OMHA asking that the appeal, other than an appeal of a QIC dismissal, be escalated to the Council. After OMHA receives a valid request for escalation, they will issue a decision, dismissal, or remand order if an OMHA adjudicator is able to issue one within 5 calendar days of receiving the request for escalation, or 5 calendar days from the end of the applicable adjudication period (whichever is later). Otherwise, OMHA will forward the case file to the Council and send a notice stating that the appeal has been escalated.

The link to the webpage for the Office of Medicare Hearings and Appeals: http://www.hhs.gov/omha