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Hearing by an Administrative Law Judge (ALJ)

If the Part C Independent Review Entity (IRE) upholds a Medicare health plan's adverse decision, the enrollee or enrollee's representative may appeal the IRE's decision by requesting an Administrative Law Judge (ALJ) hearing.

The appeal request must be filed within 60 calendar days from the date of the notice of the IRE's reconsideration decision.

All requests must be made in writing.

For more information about requesting a hearing with an ALJ, see section 100.1 in Chapter 13 of the Medicare Managed Care Manual 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 2013, the amount in controversy (AIC) must be at least $140.  For calendar year 2014, the amount in controversy must be at least $140.  For more information regarding AIC amounts, click on the links in the "Related Links" section below.    

For more information about how the amount remaining in controversy is computed, see section 100.2 in Chapter 13 of the Medicare Managed Care Manual in the "Downloads" section below.

The Office of Medicare Hearings and Appeals (OMHA) is responsible for administering ALJ hearings.  For more information about how to request an ALJ hearing or contact the Office of Medicare Hearings and Appeals, click on the link in the "Related Links" section below.

If the ALJ's decision is unfavorable to the enrollee, the decision will contain the information an enrollee needs to file a request for review by 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.