Third Level of Appeal: Hearing by an Administrative Law Judge

Following the Qualified Independent Contractor's (QIC's) decision, a party to the reconsideration may request an Administrative Law Judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration.  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 2012 the amount in controversy must be at least $130.  For calendar year 2013, the amount in controversy must be at least $140.   

You may view the Federal Register notices on the 2012 and 2013 amounts in controversy by clicking on the links in the "Related Links" section below.

Filing a Request for an ALJ Hearing

Refer to the reconsideration decision letter from the QIC for details regarding the procedures for requesting an ALJ hearing. The standard form CMS-20034 A/B may be used to file a request for an ALJ hearing. To link to this form, scroll down to "Related Links".

ALJ hearings are generally held by video-teleconference (VTC) or by telephone. If you do not want a VTC or telephone hearing, you may ask for an in-person hearing. An appellant must demonstrate good cause for requesting an in-person hearing, and the ALJ will determine whether an in-person hearing is warranted on a case-by-case basis. Appellants may also ask the ALJ to make a decision without a hearing (on-the-record). 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.

The ALJ will generally issue a decision within 90 days of receipt of the hearing request. This timeframe may be extended for a variety of reasons including, but not limited to:

• The case being escalated from the reconsideration level

• 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 if CMS is a party

If the ALJ cannot issue a decision in the applicable timeframe, the ALJ will notify the appellant of their right to escalate the case to the Medicare Appeals Council.  

A link to the webpage for the Office of Medicare Hearings and Appeals can be found below in "Related Links."