Hearing by an Administrative Law Judge (ALJ)
If the Part C Independent Review Entity (IRE) issues an adverse reconsideration decision, any party to the reconsideration (except the Medicare Advantage organization) may appeal the IRE's decision by requesting an Administrative Law Judge (ALJ) hearing. The Office of Medicare Hearings and Appeals (OMHA) is responsible for administering ALJ hearings and attorney adjudicator reveiws. For more information on OMHA and how to contact them, click on the link to "The Office of Medicare Hearings and Appeals" in the "Related Links" 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 2019, the amount in controversy is $160. For calendar year 2020, the amount in controversy rises to $170. To view the Federal Register AIC notices, see the "Related Links" section below. The appeal request must be made in writing and be filed within 60 calendar days from the date of receipt of the IRE's reconsideration decision notice. A written request may be made using the form "OMHA-100". A link to the OMHA-100 form: https://www.hhs.gov/sites/default/files/OMHA-100.pdf
If the ALJ’s decision is unfavorable, the decision will contain information needed to file a request for review by the Medicare Appeals Council.
Attorney Adjudicator Review
In order to have an attorney adjudicator review the administrative record, in lieu of attending an ALJ hearing, appellants may fill out the “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104) and submit it with your request for a hearing. The direct link to form “OMHA-104”: https://www.hhs.gov/sites/default/files/OMHA-104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf.
For more information about requesting a hearing with an ALJ or a review of the administrative record by an attorney adjudicator, or information about how the amount in controversy is computed, see section 70 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the "Downloads" section below.