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Appeals Level 3: Administrative Law Judge

Request for Administrative Law Judge Hearing – OMHA-100

There are three situations where a party can request a hearing before an ALJ:

    • A party to a QIC reconsideration may request a hearing before an ALJ if the party files a written request for an ALJ hearing within 60 days after receipt of the notice of the QIC’s reconsideration and the amount in controversy requirement is met;
    • A party who files a timely appeal before a QIC and whose appeal continues to be pending before a QIC at the end of the QIC’s decision-making timeframe has a right to a hearing before an ALJ if the party files a written request with the QIC to escalate the appeal to the ALJ level after the adjudication period expires and the QIC does not issue a final action within 5 days of receiving the request for escalation. A party wishing to escalate an appeal must also meet the amount in controversy requirement; and
    • A party to a QIC’s dismissal of a request for reconsideration has a right to have the dismissal reviewed by an ALJ if the party meets the amount in controversy requirement.

Amount in Controversy

$160

For appeals filed in calendar year 2018, the minimum amount in controversy required for an Administrative Law Judge hearing or review of a dismissal is $160.  

The amount in controversy is generally calculated in the following manner:

    • You specifically request aggregation of the claims in the same request for ALJ hearing, or in multiple requests for hearing filed with the same request for aggregation;
    • The claims were previously reconsidered by a QIC;
    • Your request for hearing lists all claims to be aggregated and is filed within 60 calendar days after receipt of all reconsiderations being appealed; and
    • The OMHA adjudicator determines that the claims involve similar or related services.    

1.      Amount charged minus Medicare payments already made or awarded = subtotal balance

2.      Subtotal balance minus any applicable deductible/coinsurance that may be collected = amount in controversy

Where Parties File Requests

To receive an ALJ hearing, a party to the QIC’s reconsideration must file a written request for an ALJ hearing with the entity specified in the QIC’s reconsideration. The appellant must also send a copy of the request for hearing to the other parties. Failure to do so will toll the ALJ’s 90-day adjudication deadline until all parties to the QIC reconsideration receive notice of the requested ALJ hearing. Also, if the request for hearing is timely filed with an entity other than the entity specified in the QIC’s reconsideration, the ALJ’s deadline for deciding the appeal begins on the date the entity specified in the QIC’s reconsideration (i.e., the appropriate Office of Medicare Hearings and Appeals (OMHA) field office) receives the request for hearing.

Timely Filing Requirements

A party must file an ALJ request within 60 days of the date of their receipt of the QIC’s decision. It is presumed that the appellant received the QIC’s decision within five days of the date of the QIC’s decision, unless there is a reasonable showing by the appellant to the contrary.

Content of the Request

The request for an ALJ hearing must be made in writing. The request must include all of the following:

    • The name, address, and Medicare health insurance claim number of the beneficiary whose claim is being appealed,
    • The name and address of the appellant, when the appellant is not the beneficiary,
    • The name and address of the designated representative, if any,
    • The document control number assigned to the appeal by the QIC, if any,
    • The dates of service,
    • The reasons the appellant disagrees with the QIC’s reconsideration or other determination being appealed, and
    • A statement of any additional evidence to be submitted and the date it will be submitted.

For the convenience of parties, DHHS/OMHA provides a form that may be used to request a Medicare ALJ hearing. The contractor provides copies of the form to parties upon request. It is not necessary, however, that this form be used to make a written request.

Time Limits & Responsibilities

In most cases, an ALJ will either: (1) issue a decision based on the request for an ALJ hearing; or (2) issue an order of dismissal of the appellant’s request for ALJ hearing; or (3) remand the case to the QIC.

If the ALJ decision is partially or wholly favorable to the appellant and gives a specific amount to be paid, the MAC effectuates within 30 calendar days of receipt of the effectuation notice from the AdQIC. The MAC must acknowledge receipt of the AdQIC effectuation per the Joint Operating Agreement (JOA) with the AdQIC.

If the decision is partially or wholly favorable but the amount must be computed by the MAC, it effectuates the decision within 30 days after it computes the amount to be paid to the appellant. The amount must be computed as soon as possible, but no later than within 30 calendar days of the date of receipt of the effectuation notice from the AdQIC. For effectuation of decisions that involve overpayments or underpayments where the limitation on recoupment provision applies (Section 935 of MMA), refer to IOM Pub. 100-06, Chapter 3, ยง200 for further instruction.

If clarification from the AdQIC is necessary, the MAC considers the date of the clarification the final determination for purposes of effectuation. If clarification is needed from the provider/physician/supplier (e.g., splitting charges), the MAC requests clarification as soon as possible and computes the amount payable within 30 calendar days after the receipt of the necessary clarification. The MAC considers the date of receipt of the clarification as the date of the final determination for purposes of effectuation.



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