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

If the Part D Independent Review Entity (IRE) issues an adverse reconsideration decision, the enrollee, or the enrollee's representative, may appeal the decision by requesting a hearing by an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals (OMHA). The Office of Medicare Hearings and Appeals is responsible for administering ALJ hearings. For more information about how to request a hearing with an ALJ, or waive a right to hearing and request an on the record review, or for information on the Office of Medicare Hearings and Appeals, you may click on the link titled "The Office of Medicare Hearings and Appeals" in the "Related Links" section at the bottom of this page.

An enrollee's prescriber may not request a hearing by an ALJ on an enrollee's behalf unless the enrollee's prescriber is also the enrollee's representative. For more information about appointing a representative, see section 20 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the "Downloads" section at the bottom of this page.

How to Request a Hearing by an ALJ

In order to request a hearing by an ALJ, the amount remaining in controversy (AIC) must meet the threshold requirement. This amount is recalculated each year and may change. For calendar year 2024, the amount in controversy is $180. Effective January 1, 2025, the amount in controversy threshold rises to $190. To view the Amount in Controversy Federal Register notices for calendar years 2024 and 2025, see the "Related Links" section at the bottom of this page. 

The request must be filed with the proper OMHA hearing office within 60 calendar days from the date of the IRE's reconsideration decision notice. Requests for standard hearings must be made in writing. Requests for expedited hearings may be made verbally or in writing. A written request may be made using the form "OMHA-100". A link to the OMHA-100 form and all other OMHA forms can be found at the bottom of this page in "Related Links".

If the ALJ's decision is unfavorable, the decision notice will contain the information needed to file a request for review with 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

In order to have an attorney adjudicator or ALJ review the administrative record, in lieu of attending an ALJ hearing, appellants should fill out the “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104) and submit it with your request for an ALJ hearing. The ALJ may require the enrollee to participate in a hearing if it is necessary to decide the case. If the ALJ determines that it is necessary to obtain testimony from a person other than the enrollee, he or she may hold a hearing to obtain that testimony, even if the enrollee has waived the right to appear. In that event, however, the ALJ will give the enrollee the opportunity to appear when the testimony is given, but may hold the hearing even if the enrollee decides not to appear.  The link to form “OMHA-104" and all other OMHA forms can be found at the bottom of this page in "Related Links".

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