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).
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 below.
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 2020, the amount in controversy is $170. For calendar year 2021, the amount in controversy is $180. To view the Federal Register AIC notices, see the "Related Links" section below.
For more 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 below.
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 can be found below in, "Related Links."
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 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 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 direct link to form “OMHA-104" can be found below in, "Related Links."