Fact Sheet
FOR IMMEDIATE RELEASE
August 15, 2006 |
Contact: HHS Press Office
(202) 690-6343
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Office of Medicare Hearings and Appeals
What is the Office of Medicare Hearings and Appeals?
Working as an 'internal independent examiner' of Medicare cases, the Office of Medicare Hearings and Appeals (OMHA) at the U.S. Department of Health and Human Services (HHS) provides the opportunity for individuals and organizations who are dissatisfied with Medicare initial determinations to have a hearing in front of an Administrative Law Judge, called an "ALJ."
OMHA is led by a Chief Administrative Law Judge who reports directly to the HHS Secretary. OMHA consists of a Central Office and 4 Field Offices located in Arlington, Virginia; Cleveland, Ohio; Miami, Florida and Irvine, California.
Created by the Medicare Modernization Act (MMA) of 2003, OMHA became fully operational on July 1, 2005. Prior to the MMA, OMHA's hearings and appeals function was carried out in part by the Social Security Administration (SSA), which was formerly part of HHS until 1995.
Within OMHA, an ALJ issues the determination of the Secretary on administrative appeals involving Medicare entitlement and claims appeals for Part A, Part B, Part C, and as of January 2006, Part D.
What is the mission of OMHA?
OMHA's mission is to administer the nationwide hearings and appeals for the Medicare program. OMHA also ensures that the American people have equal access and opportunity to appeal and can exercise their rights for health care quality and access. To aid OMHA in accomplishing this mission, OMHA uses video teleconferencing technology and the Medicare Appeals System to improve time and value in managing the hearings process.
What is Video Teleconferencing technology?
Video Teleconferencing (VTC) technology is used in federal, state, and local courtrooms across the country. VTC involves a 2-way television connection that creates a face-to-face experience by sending verbal and visual communication from one location to another location at the same time.
For example, you might be at a local conference facility, while the ALJ is located in an OMHA field office. VTC allows hearings to be scheduled more quickly and at easily accessible locations. Locations may include OMHA offices nationwide and HHS regional offices throughout the country.
When you participate in a VTC hearing, you and your representative (for example, a lawyer or other qualified person to represent you) will be present in a location with a private room. Everyone will be able to see and hear one another because each room has its own video monitor and video camera.
The video monitor allows you to hear and see what happens in a distant room as it actually occurs � just like watching a live television broadcast. The monitor allows you to see and hear the ALJ, and the camera allows the ALJ to see and hear you. In appropriate circumstances, you or your representative will be able to request an in-person hearing, which involves waiving the general 90-day decision timeframe. An ALJ may also determine that an in-person hearing is appropriate.
What is the Medicare Appeals System?
To improve the appeals process, the Medicare Appeals System (MAS), an electronic unified case tracking system, was designed to track and transfer case specific information throughout all levels of the appeals process.
In addition to basic case tracking, MAS provides the capability to report on appeals data; enabling more accurate and useful reporting, organizational assessment, and policy-setting.
MAS also collects and sorts data and manages workflow. For example, MAS is designed to accommodate new legislative developments, such as the new appeals workload associated with the new Medicare drug benefit.
Who can appeal or request a hearing?
Medicare beneficiaries, providers, or suppliers are eligible to request hearings before an ALJ.
How many levels are involved in the appeals process?
Generally, after your initial determination, five levels of appeals exist and include:
- Redetermination by an Affiliated Contractor
- Reconsideration by a Qualified Independent Contractor (QIC)
- A Hearing by an Administrative Law Judge
- Review by the Medicare Appeals Council
- Review by a Federal District Court
What is the timeline on the hearings and appeals process?
Under the MMA of 2003, the time period for OMHA to issue decisions on cases at the third level of appeal 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. Note: Appeals at levels one, two, and four have set time frames as well.
What do I need to know to request a Medicare hearing?
You have the right to appeal any determination that is made on your Medicare eligibility, enrollment, or a claim for your benefits under Part A, Part B, or Part C and as of January 1, 2006, Part D.
If you are dissatisfied with the initial determination, you or your representative may request a redetermination; the redetermination is the first level of appeal and is decided by the affiliated contractor.
The second level of appeal is a reconsideration, in which a QIC not involved in the initial or redetermination will perform an independent review of the evidence and findings submitted by you, your representative, or the contractor.
If you or your representative is dissatisfied with a reconsideration, then generally you must file a written request for an ALJ hearing within 60 days from receipt of the Notice of Reconsideration.
The Notice of Reconsideration has information on how to request an ALJ hearing. The address for the applicable OMHA Field Office is also contained in the notice.
Where can I find the forms?
Medicare appeals forms, including:
- Request for Medicare Hearing Before an ALJ
- Medicare Redetermination Request
- Medicare Reconsideration Request
- Appointment of Representative
- Transfer of Appeal Rights
are available on the Internet at www.medicare.gov/basics/forms
Additional forms from the Centers for Medicare and Medicaid Services (CMS) can be found on the web at www.cms.hhs.gov/forms.
How do I contact the OMHA Field Offices?
Mid-Atlantic Field Office
Arlington, Virginia
Phone: 1-866-231-3087
Mid-West Field Office
Cleveland, Ohio
Phone: 1-866-236-5089
Western Field Office
Irvine, California
Phone: 1-866-495-7414
Southern Field Office
Miami, Florida
Phone: 1-866-622-0382
For more information
The OMHA website provides additional information to Medicare beneficiaries, families, representatives, providers, suppliers, and advocacy organizations involved in the Medicare appeals process. For more information about OMHA and its field offices, please visit our website at www.hhs.gov/omha.
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Note: All HHS press releases, fact sheets and other press materials are available at http://www.hhs.gov/news.
Last Revised: August 16, 2006
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