What You Need To Know To Request a Medicare Hearing Before an Administrative Law Judge

What You Need To Know To Request a Hearing
If dissatisfied with an initial determination, an appellant or his or her representative may request a redetermination of that decision or determination, the first level of appeal, with the Affiliated Contractor (or Fiscal Intermediary or Carrier). A person at the Affiliated Contractor (or Fiscal Intermediary or Carrier) not involved in the initial determination will conduct an independent review of the initial determination, including a review of the evidence, findings and additional evidence submitted by parties or obtained by the Affiliated Contractor.

The second level of appeal is called a "reconsideration" and it is completed by a Qualified Independent Contractor or QIC. Similar to the first level of appeal, the QIC will conduct an independent, on-the-record review of your case. The QIC has not had any involvement in the initial determination or redetermination. The QIC will send the appellant or their representative a letter explaining how they made the reconsideration.

If an appellant disagrees with the QIC's reconsideration, he or she has the right to request a hearing before an Administrative Law Judge (ALJ), the third level of appeal. Appellants, or their representatives, dissatisfied with a reconsideration generally must file written requests for an ALJ hearing within 60 days from receipt of the notice of reconsideration. In addition, the appeal must be above $110 (in Fiscal Year 2006) in order for the ALJ to hear the case. Information on how to file an appeal is contained in the Notice of Reconsideration received from the QIC. The address for the correct field office is also contained in that Notice. Addresses and contact information for all of the OMHA field offices can be found at http://www.hhs.gov/omha/offices.html.

In the fourth level of appeal, if the appellant or his or her representative disagrees with the decision of the ALJ, a request for review may be filed with the Medicare Appeals Council (MAC).

Finally, at the fifth level of appeal, under certain circumstances, the appellant or his or her representative may appeal the MAC's decision to the appropriate Federal District Court.

Please follow the instructions below when filing your Request for a Medicare Hearing before an ALJ.

  • If your reconsideration determination was issued by a Qualified Independent Contractor please use form CMS-20034A/B [PDF - 38 KB].
  • If your reconsideration or fair hearing determination was issued by a Fiscal Intermediary, Carrier, or Quality Improvement Organization please use form CMS-5011A/B [PDF - 41 KB].
  • If you wish to appoint a representative to act on your behalf in exercising your right to an initial determination or appeal, please use form CMS-1696 [PDF – 10 KB].

All CMS forms can be found at http://www.cms.hhs.gov/forms/.

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When To Request a Hearing
The hearing process generally begins after a QIC has issued a reconsideration. If you are dissatisfied with the reconsideration issued by a QIC, you or your representative may request a hearing before an ALJ. The ALJ will make an independent decision based on the evidence submitted and that the ALJ obtains, including any testimony that you provide at the hearing.

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How To Request a Hearing
To request a hearing, please follow the instructions in the reconsideration notice from the QIC. The reconsideration notice from the QIC will contain information concerning which OMHA field office to contact to request an ALJ hearing. If you have additional questions, please contact the OMHA field office and they will answer your questions.

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Development of Your Case
As soon as your request for hearing is received by an OMHA field office, our staff sets up a computer file to keep track of your case.

The OMHA field office staff makes sure that we have all the materials used in processing your claim and all the medical and other evidence that may be available from other sources. If any of this material appears to be missing, we will request it.

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Your Right to Representation
You may want a lawyer, friend, or other qualified person to represent you. If you decide to have a representative, you need to tell us by filling out a special form (CMS 1696 -
Appointment of Representative). If you have a representative, you may have to pay his or her fees.

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Appointing a Representative
An appointed representative may act on behalf of an individual or entity in exercising his or her right to an initial determination or appeal. The
Appointment of Representative form (CMS 1696) must be used. An appointment of representation must:

  • Be in writing and signed and dated by both the party and individual agreeing to be the representative;
  • Provide a statement appointing the representative to act on behalf of the party, and in the case of a beneficiary, authorizing the adjudicator to release identifiable health information to the appointed representative;
  • Include a written explanation of the purpose and scope of the representation;
  • Contain both the party’s and appointed representative’s name, phone number, and address;
  • Identify the beneficiary’s Medicare health insurance claim number;
  • Include the appointed representative’s professional status or relationship to the party;
  • Be filed with the entity processing the party’s initial determination or appeal. Unless revoked, an appointment is considered valid for 1 year from the date that the Appointment of Representative form is signed. Once the form is filed with the person or entity handling the initial determination or appeal, the representation is valid for the duration of the individual’s appeal.

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Fees for Appointed Representatives
An appointed representative for a beneficiary who wishes to charge a fee for services rendered in connection with an appeal at the ALJ level must obtain approval of the fee from the ALJ.

No award of attorney’s or any other representative’s fees or any costs in connection with an appeal may be made against the Medicare trust funds.

A provider or supplier that furnished the items or services to a beneficiary that are the subject of the appeal may represent that beneficiary in an appeal under this subpart, but the provider or supplier may not charge the beneficiary any fee associated with the representation. In addition, the provider or supplier may not represent the beneficiary on the issues described in section 1879(a)(2) of the Act, unless the provider or supplier waives the right to payment from the beneficiary for the services or items involved in the appeal.

For more information on fee agreements, including the reasonableness of representative fees, please contact your Office of Medicare Hearings and Appeals field office.

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Time Limits for Appealing to the OMHA ALJ
You or your representative may file a written request for appeal of a reconsideration within 60 days from receipt of the notice of reconsideration with the entity specified in the reconsideration notice. If you do not file an appeal within 60 days, the ALJ may dismiss your appeal. This means that you may not be eligible for the next step in the appeal process and that you may also lose your right to any further administrative or judicial review.

If you file an appeal after the 60-day deadline, you must explain the reason you are late and request that we extend the time limit. The OMHA field office staff can explain further and help you file a written request to extend the time limit.

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When and Where the Hearing Is Held
Generally, once the appeal is received by the OMHA field office, a hearing will be scheduled. The OMHA field office will attempt to schedule all hearings promptly. There are four field offices nationwide and hundreds of videoteleconference (VTC) sites where hearings may be held. This extensive network assists us in providing you with ready access to hearings, even in remote locations. It also lessens the likelihood that you may need to travel far for your hearing.

Before your hearing, we will send you a notice telling you the date, time, and place of the hearing. The ALJs hold hearings through VTC, over the telephone, or in person. The ALJs will hold most hearings by VTC or over the telephone unless the ALJ determines that there are special or extraordinary circumstances. As an alternative, an appellant may request an in-person hearing, which may be granted if good cause is shown.

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Why You Should Have Your Hearing by Videoteleconference (VTC)
Often an appearance by VTC can be scheduled faster than an in-person appearance and that means less waiting time for your hearing. Also, a VTC hearing location may be closer to your home and that might make it easier for you to have witnesses or other people accompany you.

A VTC hearing allows you and the other hearing participants to see and hear each other through large color television screens. The ALJ remains in his or her location, and you go to a site that is generally more convenient to where you live. A technician is there to make sure the equipment works smoothly, but the technician does not listen in on the hearing. No one except your representative or someone else you might choose, witnesses at the hearing, or others that the ALJ considers necessary and proper will be allowed to listen in or view the hearing. You will be able to see, hear and talk to the ALJ at the hearing.

We realize that not everyone is familiar with how VTC works. The OMHA field office staff will be glad to answer any questions you might have concerning VTC hearings.

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How Is a VTC Hearing Different?
The ALJ can see you and speak with you and anyone who comes to the hearing with you, such as your representative or any witnesses. You can see the ALJ and anyone who is with the ALJ -- or anyone at another VTC site, such as a medical or non-medical expert. Transmission of the hearing is secure, and your privacy is protected. We do not videotape hearings, but we do make audio recordings -- as we do for all hearings.

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How Is a VTC Hearing Scheduled?
If we are using VTC equipment in your area, we will contact you to schedule a VTC hearing for you at a convenient time. The ALJ will consider any preference you may have expressed for or against appearing by VTC when setting the time and place of your hearing. You will have an opportunity to object to the set time or place. If you have any questions or want more information, please contact your OMHA field office when you receive your acknowledgment of your request for a hearing.

A hearing clerk in the OMHA field office will have a list of the VTC sites located nearest to your home, and will work with you in selecting a site for the hearing.

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Steps in the Hearing Process

Before the hearing:

  • You and your representative, if you have one, may look at the evidence in your case file and under certain circumstances, you may be able to submit new evidence.
  • It is very important that you submit any new evidence within 10 days of receiving the Notice of Hearing.

At the hearing:

  • The ALJ explains the issues in your case and may question you and any witnesses you bring to the hearing.
  • The ALJ may ask other witnesses, such as a doctor or other experts, to come to the hearing.
  • You and the witnesses answer questions under oath. The hearing is informal, but we do make audio recordings.

After the hearing:

  • The ALJ issues a written decision after considering all the evidence.
  • The ALJ sends you and your representative, if you have one, a copy of the decision.

If You Do Not Wish To Appear or Cannot Appear at the Hearing
If you do not wish to appear in person at the hearing, you must let us know in writing when you request the hearing or before the hearing date. You may state your reasons, and ask the ALJ to make a decision based on the evidence in your file.

The ALJ may decide that your presence at the hearing will be helpful, especially if only you can best explain certain facts. If so, the ALJ may require your presence.

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You Should Go to a Scheduled Hearing
If you wish to appear at a hearing and the ALJ schedules a hearing, you and your representative, if you have one, should attend. It is very important that you attend a scheduled hearing. If for any reason you cannot attend, contact the ALJ as soon as possible before the hearing and state the reason.

The ALJ will reschedule the hearing that you do not attend if you have provided a good reason for not going. If you do not go to a scheduled hearing and the ALJ decides that you do not have a good reason for not going, your request for hearing may be dismissed.

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When We Can Pay Travel Expenses
If it is determined that you must travel more than 75 miles from your home or office to attend a VTC hearing, we may be able to pay certain costs. Here are the general policies that apply:

  • We may be able to pay your transportation expenses such as the cost of a taxi, bus ticket or expenses for driving your car, or travel by rail in some cases. An ALJ may not authorize payment for transportation by airplane.

  • The ALJ may also approve payment of similar travel expenses for your representative and any witnesses the ALJ determines are needed at the hearing.

  • You must submit a written request for payment of travel expenses to the ALJ at the time of the hearing or as soon as possible after the hearing. List what you spent and include supporting receipts. If you requested a change in the scheduled location of the hearing to a location farther from your residence, we cannot pay for any additional travel expenses beyond the original location of the hearing.

Please contact our OMHA field office staff to answer any questions you might have concerning payment of travel expenses.

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Tips to Shorten the Hearing Process
Help Us Process Your Hearing As Quickly As Possible. There are a number of things you can do to speed up the processing of your request for a hearing.

  • If you wish to appoint a representative, do so as early as possible. Your representative will want time to review your file and prepare for the hearing. If you wait until the date of the hearing or shortly before, your hearing may have to be postponed to provide the representative with the necessary preparation time. Rescheduling a hearing adds a substantial amount of time to the processing of your hearing request.

  • Make sure that any new or updated evidence you want considered has been submitted either with the Request for the ALJ hearing, or within 10 days of receiving the Notice of the ALJ hearing by either you or your representative (the earlier the better). This evidence may result in an early favorable decision for you, eliminating the need for a hearing. If a hearing is necessary, the early submission of this evidence will eliminate the delays caused because additional evidence has not yet been received.

  • Notify us of any changes in your address immediately.

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How Long the Process Takes
We receive many requests for information about the hearing process from appellants and/or their representatives. Most of the time, these requests relate to how soon the hearing will be scheduled and how long it may take an ALJ to make a decision in his or her case. The information below may answer some of your questions.

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Average Time for Your Hearing
For Medicare Part A and Part B claims appeals cases that come from QIC reconsiderations, the ALJs generally must complete their review and render a decision within a 90-day timeframe. However, each case is unique and under certain circumstances some cases may take more or less time to complete than others.

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Scheduling of Your Hearing
Generally, our ALJs set their hearing schedules a few weeks ahead of time. Your hearing may take longer to schedule if we need to schedule a medical or non-medical expert to testify, or if your attorney or other representative cannot be present on the date we select.

  • You will receive a written notice of hearing at least 20 days before your hearing is scheduled.
  • OMHA field office staff will work with you to arrange details associated with going to a VTC site to participate in the hearing.
  • If you choose to participate and cannot participate in the scheduled hearing for some reason, you must contact the ALJ as soon as possible to request a postponement. Only the ALJ can decide whether your hearing can be rescheduled.
  • You should plan to arrive at the VTC hearing site at least ½ hour before the scheduled time of your hearing.

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After Your Hearing

  • After the ALJ holds your hearing, he or she may decide that additional evidence must be obtained is needed.
  • After the ALJ is satisfied that all the relevant evidence is in the record, he or she will prepare the decision in your case.

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Medicare Appeals Review
For more information on the Medicare Appeals Council, please see its website located at

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Tips for a Timely Review Process

  • Make sure you request review within 60 days after you receive the OMHA ALJ hearing decision. If you are unable to meet this deadline, explain your reasons for missing it in your request.

  • We request that you do not make automatic, multiple requests for the status of your request for review.

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Please consult the Secretary’s regulations at 42CFR Part 405, Subpart 1, for a full and accurate description of the appeal process.

Last revised: September 27, 2006