CMS 5011A-B

Submitted by Matthew.Gregor… on Mon, 11/04/2019 - 07:06
Form #
CMS 5011A-B
Form Title
REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE
Revision Date
2017-01-01
O.M.B. #
Obsolete
CMS Manual
N/A
Special Instructions
CMS-5011A-B has been discontinued. The form “Request for Medicare Hearing by Administrative Law Judge - CMS-5011A-B” has been discontinued. It has been replaced by the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100.” This change is effective January 2017.
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The new form can be found on the Office of Medicare Hearings and Appeals (OMHA) website at:<br />
<a href="https://www.hhs.gov/about/agencies/omha/filing-an-appeal/forms/index.html">https://www.hhs.gov/about/agencies/omha/filing-an-appeal/forms/index.html</a>
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The direct link to the new form “OMHA-100”:<br />
<a href="https://www.hhs.gov/sites/default/files/OMHA-100-Request-for-Hearing-or-Review-of-Dismissal.pdf">https://www.hhs.gov/sites/default/files/OMHA-100-Request-for-Hearing-or-Review-of-Dismissal.pdf</a>
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In addition, the form OMHA 100A is used as an attachment to form OMHA 100 to identify multiple beneficiaries or enrollees associated with a single request for an Administrative Law Judge (ALJ) hearing or a review of dismissal. The direct link to form “OMHA-100A”:<br />
<a href="https://www.hhs.gov/sites/default/files/OMHA-100A-Multiple-Claim-Attachment.pdf">https://www.hhs.gov/sites/default/files/OMHA-100A-Multiple-Claim-Attachment.pdf</a>