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If you are not sure which procedures apply, please follow these instructions to appeal. We will apply the right procedures to your case:

If you do not agree with the Administrative Law Judge’s (ALJ’s) decision or dismissal order, you may appeal to the Medicare Appeals Council. Other parties may also appeal. We call an appeal to the Medicare Appeals Council a “request for review.” The Medicare agency may also ask the Medicare Appeals Council to review the ALJ’s decision or dismissal order on its own motion.

You may appoint an attorney or other person to represent you. Legal aid groups may provide legal services at no charge.

What to Include in your Appeal

You should use the form DAB-101 to appeal. You may also appeal in writing if you provide:

• the beneficiary's name;
• the beneficiary's health insurance claim number;
• the item or service in dispute;
• the date of the item or service;
• the date of the ALJ’s decision; and
• your name and signature, or the name and signature of your representative;

Please send a copy of the ALJ’s decision or dismissal order with your appeal.

How to File an Appeal

You must file an appeal within 60 days after you receive the ALJ’s decision or dismissal order. The Medicare Appeals Council will assume that you received the ALJ’s action five days after the date on the decision or dismissal order, unless you show that you received it later. If you file the appeal late, you must show that you had good cause.

Mail the appeal to:

Department of Health and Human Services
Departmental Appeals Board
Medicare Appeals Council, MS 6127
Cohen Building Room G-644
330 Independence Ave., S.W.
Washington, D.C. 20201.

Or you may fax the appeal to (202) 565-0227. If you send a fax, please do not also mail a copy. You must send a copy of your appeal to the other parties.

If you have questions about the Medicare Appeals Council, you may call (202) 565-0100.

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