Hearing by an Administrative Law Judge

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).

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 10.4 in Chapter 18 of the Prescription Drug Benefit Manual.  You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" 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 2011, the amount in controversy threshold is $130.  For calendar year 2012, the amount in controversy threshold will remain at $130.

For more information about how the amount remaining in controversy is computed, see section 90.2 in Chapter 18 of the Prescription Drug Benefit Manual.  You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" section below.

The request must be filed with the proper ALJ 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 orally or in writing.

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 the Office of Medicare Hearings and Appeals, you may click on the related link in the "Related Links Outside CMS" section below.

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 navigation tool on the left side of this page to link to subpages that contain detailed information about reviews by the Medicare Appeals Council or any other level of appeal.

Downloads
Chapter 18 of the Prescription Drug Benefit Manual [zip, 302kb]
Related Links Inside CMS
There are no Related Links Inside CMS
Related Links Outside CMS
The Office of Medicare Hearings and Appeals Amount in Controversy Requirement for CY 2011 Amount in Controversy Requirement for CY 2012

Page Last Modified: 09/28/2011 9:05:31 AM
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