Office of Medicare Hearings and Appeals (OMHA)Frequently Asked Questions| Category | Questions |
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| Levels of the Appeals Process | - 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]
- What is Level 4 of the Medicare appeals process? [Answer]
- What is Level 5 of the Medicare appeals process? [Answer]
| | Organizations | - What is the Office of Medicare Hearings and Appeals? [Answer]
- What is the Departmental Appeals Board? [Answer]
- What is the Medicare Appeals Council? [Answer]
| | OMHA Appeal | - 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]
- How do I appeal a determination of the Income-Related Monthly Adjustment to the amount of Part B Supplementary Insurance program? [Answer]
| | Types of Medicare | - 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 Original Medicare? [Answer]
- What is the Medicare Prescription Drug program? [Answer]
- What is the Medicare Part B Income-Related Monthly Adjustment Amount (IRMAA)? [Answer]
| | Representation | - How do I appoint a person to represent me in a Medicare appeal? [Answer]
- How long will my appointed representative remain my representative? [Answer]
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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 entitlement and Part B premium appeals. OMHA’s mission is to administer the nationwide hearings and appeals for the Medicare program.
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The appeals process is described in the section titled Understanding the Appeals Process.
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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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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. These are the names of Level 1 appeals for each part of the Medicare program: | Name | Medicare Part |
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| Initial determination | Parts A & B, Original Medicare: Includes the Hospital Insurance program (Part A) and Supplementary Medical Insurance program (Part B) | | Organization determination | Part C, the Medicare Advantage program | | Coverage determination | Part D, the Medicare Prescription Drug program |
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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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Level 3 is described in the section titled Level 3: OMHA.
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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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The timeline for issuing a decision differs depending on the type of Medicare you have, the level of the appeal, and certain special circumstances. To learn more, see Appeals Process by Medicare Type. 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 may be waived. OMHA is committed to providing the most timely decisions possible for all appeals at Level 3.
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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 & B, 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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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:
Amount Charged: $500
Unmet deductible: - 50
____________________________________
Subtotal Balance: $450
Amount Allowed: - 150
____________________________________
Balance: $300
x 0.80
____________________________________
Remaining Amount in Controversy: $240
This example satisfies the current Amount in Controversy (AIC) requirement. In 2008, the AIC must be $120 or more for an ALJ hearing at Level 3 of the Medicare appeals process.
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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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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 its ALJs. The Medicare Appeals Council is a division of the DAB.
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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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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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The procedure for appointing a representative is described in the section titled Your Right to Representation.
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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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The procedure for appealing an Income-Related Monthly Adjustment amount is described in the section titled Part B Premium Appeals.
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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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Part A Hospital Insurance and Part B Supplementary Medical Insurance are often called “Original Medicare.”
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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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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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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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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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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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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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