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Form #
CMS 5011A-B
Form Title
REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE
Revision Date
2017-01-01
O.M.B. #
Obsolete
O.M.B. Expiration Date
N/A
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 It has been replaced by the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100.”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.

The new form can be found on the Office of Medicare Hearings and Appeals (OMHA) website at:
https://www.hhs.gov/about/agencies/omha/filing-an-appeal/forms/index.html

The direct link to the new form “OMHA-100”:
https://www.hhs.gov/sites/default/files/OMHA-100-Request-for-Hearing-or-Review-of-Dismissal.pdf

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”:
https://www.hhs.gov/sites/default/files/OMHA-100A-Multiple-Claim-Attachment.pdf