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Office of Medicare Hearings and Appeals (OMHA)

Frequently Asked Questions

  • What is the Office of Medicare Hearings and Appeals? [Answer]
  • How does the appeals process work? [Answer]
  • What is a “level” of the Medicare appeals process? [Answer]
  • What is Level 1 of the Medicare appeals process? [Answer]
  • What is Level 2 of the Medicare appeals process? [Answer]
  • What is Level 3 of the Medicare appeals process? [Answer]
  • Who can request a hearing with OMHA? [Answer]
  • What is the timeline on the hearings and appeals process? [Answer]
  • What do I need to know to request a Medicare hearing with an Administrative Law Judge? [Answer]
  • How is the Amount in Controversy (AIC) calculated? [Answer]
  • What is Level 4 of the Medicare appeals process? [Answer]
  • What is the Departmental Appeals Board? [Answer]
  • What is the Medicare Appeals Council? [Answer]
  • What is Level 5 of the Medicare appeals process? [Answer]
  • How do I appoint a person to represent me in a Medicare appeal? [Answer]
  • How long will my appointed representative remain my representative? [Answer]
  • How do I appeal a determination of the Income-Related Monthly Adjustment to the amount of Part B Supplementary Insurance program? [Answer]
  • What is the Medicare Part B Income-Related Monthly Adjustment Amount (IRMAA)? [Answer]
  • What is Original Medicare? [Answer]
  • What is the Medicare Prescription Drug program? [Answer]
  • What is a "part" of the Medicare program? [Answer]
  • What is Part A of the Medicare program? [Answer]
  • What is Part B of the Medicare program? [Answer]
  • What is Part C of the Medicare program? [Answer]
  • What is Part D of the Medicare program? [Answer]

 

 


What is the Office of Medicare Hearings and Appeals?

The Office of Medicare Hearings and Appeals (OMHA) at the U.S. Department of Health and Human Services (HHS) provides an opportunity for individuals and organizations who are dissatisfied with Medicare initial decisions about Medicare benefits or eligibility to have a hearing in front of an Administrative Law Judge.  The Office of Medicare Hearings and Appeals (OMHA) is responsible for  Level 3 of the Medicare claims appeal process and certain  Medicare-related appeals from the Social Security Administration.  OMHA’s mission is to administer the nationwide hearings and appeals for the Medicare program. 

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How does the appeals process work?

Please see the section entitled Understanding the Appeals Process.

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What is a “level” of the Medicare appeals process?

One of five phases in the Medicare appeals process at which a Medicare beneficiary or appointed representative can challenge a prior decision about a Medicare benefit before proceeding to a higher level decision-maker.  There are five levels in the Medicare appeals process.  

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What is “Level 1” of the Medicare appeals process?

At Level 1, your appeal has different names depending on the part of Medicare under which the medical services or items were provided.  For more information, see the section on Level 1 Appeals.

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What is “Level 2” of the Medicare appeals process? 

At Level 2, your appeal has different names depending on the part of Medicare under which the medical services or items were provided.  For more information, see the section on Level 2 Appeals.

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What is “Level 3”of the Medicare appeals process? 

To learn more about Level 3, see the section on Level 3 Appeals: OMHA.

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Who can request a hearing with OMHA?

Medicare beneficiaries, providers, or suppliers are eligible to request hearings with the Office of Medicare Hearings and Appeals (OMHA).  OMHA handles Level 3 in the Medicare claims appeals process. You can request a hearing with OMHA if you are dissatisfied with a decision made at Level 2 of the appeals process and you meet the amount in controversy (AIC) requirement. The AIC is the value of your claim and it must be $120 or more in 2008.

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What is the timeline on the hearings and appeals process?

The timeline for issuing a decision differs depending on the type of Medicare you have, the level of the appeal, and certain special circumstances.  See charts of the Medicare appeals process for more information.  The time period for OMHA to issue decisions on cases at Level 3 of the appeals process is no more than 90 days (for appeals conducted by phone or VTC). For some in-person hearings, the 90-day time period is waived. OMHA is committed to providing the most timely decisions possible for all appeals at Level 3.

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What do I need to know to request a Medicare hearing with an Administrative Law Judge (ALJ)?

You have the right to appeal any issue not decided entirely in your favor regarding your Medicare eligibility, enrollment, premium, or coverage of items or services under Part A, Part B, or Part C or Part D of the Medicare program.

You can request a hearing at Level 3 if you are dissatisfied with the decisions made at Level 2 of the appeals process.  You will also have to meet the amount in controversy (AIC) requirement. The AIC is the value of your claim.  In 2008, the AIC must be $120 or more for an ALJ hearing at Level 3 of the Medicare appeals process.  At each level, you will receive written instructions on how to continue to the next level of appeal if you wish to do so

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How is the Amount in Controversy (AIC) calculated?

The amount in controversy is calculated in the following manner:

1. Amount Charged - Unmet Deductible = Subtotal Balance
2. Subtotal Balance - Amount Allowed = Balance
3. Balance x 80% = Amount in Controversy

Example:
Charge: $500
Unmet deductible: 50
____________________________
Subtotal Balance 450
Allowed 150
Balance x 0.80
____________________________
Amount in controversy $120

 

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What is “Level” 4 of the Medicare appeals process?

At Level 4 of the appeals process, a beneficiary can appeal the decision of the OMHA Administrative Law Judge to the Medicare Appeals Council of the Departmental Appeals Board within the U.S. Department of Health and Human Services.  

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What is the Departmental Appeals Board (DAB)?

A Board established in the Office of the Secretary of the U.S. Department of Health and Human Services (DHHS) whose members act in panels to provide impartial review of disputed decisions made by operating components of the Department or by ALJs. The Medicare Appeals Council is a division of the DAB.

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What is the Medicare Appeals Council (MAC)? 

A division within Departmental Appeals Board that reviews and can hear cases following an Administrative Law Judge decision pertaining to Medicare claims and entitlement appeals.  The Medicare Appeals Council has a right to refuse to hear a case.

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What is “Level 5” of the Medicare appeals process? 

At Level 5 of the appeals process, a beneficiary can appeal the decision of the Medicare Appeals Council to the U.S. District court for the jurisdiction in which the beneficiary lives and obtain court review. 

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How do I appoint a person to represent me in a Medicare appeal?

Please see the page entitled Your Right to Representation.

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How long will my appointed representative remain my representative? 

Unless revoked, an appointment is considered valid for one year from the date the form is signed. Once the form is filed, it is valid for the duration of the appeal. Therefore, a signed form can be used for more than one appeal as long as the appeal is filed within one year of the date on the form.

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How do I appeal a determination of the Income-Related Monthly Adjustment to the amount of Part B Supplementary Insurance program? 

For more information please see the section entitled OMHA Appeals: Entitlement and Premium Issues.  

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What is the Medicare Part B Income-Related Monthly Adjustment Amount (IRMAA)?

Prior to January 2007, the Federal Government paid approximately 75 percent of the Part B premium and the beneficiary paid the remaining 25 percent.  Starting in January 2007, beneficiaries enrolled in Medicare Part B with modified adjusted gross incomes (MAGI) above a set threshold are required to pay a higher percentage of their total Part B premium costs. This is the Income-Related Monthly Adjustment Amount (IRMAA) which may also be referred to as the Medicare subsidy reduction.

This increase will be phased in from 2007 to 2009. In 2007, affected beneficiaries will pay 33 percent of the Income-Related Monthly Adjustment Amount. In 2008, affected beneficiaries will pay 67 percent and in 2009, affected beneficiaries will pay the entire Income-Related Monthly Adjustment Amount.

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What is Original Medicare?
 

Part A Hospital Insurance and Part B Supplementary Medical Insurance are often called “Original Medicare.”

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What is the Medicare Prescription Drug program? 

Under the Medicare Prescription Drug program (Part D), beneficiaries obtain help in paying for certain medications doctors prescribe for treatment.  In this program, Medicare beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.

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What is a “part” of the Medicare program?

There are four distinct health insurance programs within the Medicare program and each has its own appeals process.  These health insurance programs are referred to as “parts” as each program is set forth in separate “parts” of the Medicare statute.  It is important that you know under what “part” of the Medicare program you received medical services or items in order to appeal a decision regarding those benefits. 

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What is Part A of the Medicare program?

Part A is Medicare’s Hospital Insurance program which helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.

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What is Part B of the Medicare program?

Part B is Medicare’s Supplementary Medical Insurance program that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

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What is Part C of the Medicare program?

Part C of the Medicare program provides all Part A and Part B services and in some cases, some additional services, through Medicare Advantage health plans.

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What is Part D of the Medicare program?

Part D of the Medicare program helps pay for certain medications that doctors prescribe for treatment.  Beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.

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