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If an ALJ issued a decision after a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO), made a reconsideration or fair hearing determination, these procedures apply to your appeal:

If you do not agree with the Administrative Law Judge’s (ALJ’s) decision, you may appeal to the Medicare Appeals Council.� Other parties may appeal too.� 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 on its own motion.���

The ALJ’s decision will become final unless:

• The Medicare Appeals Council reviews the ALJ’s decision on the appeal of a party or on its own motion; or
• The Medicare Appeals Council denies the appeal of a party and a party asks for federal court review.�

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 with your appeal.��

How to File an Appeal

You must file an appeal within 60 days after you received the ALJ’s decision. �The Medicare Appeals Council will assume that you received the ALJ’s decision five days after the date shown on it, 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 may also file the appeal with any Social Security Office.� However, it will take longer to work on your case if you file anyplace except the Medicare Appeals Council.� You must send a copy of your appeal to the other parties.

The regulations at 20 C.F.R. Part 404, Subpart J, apply to this case.� If you have questions about the Medicare Appeals Council, you may call (202) 565-0100.

Medicare Appeals Council Action

The Medicare Appeals Council may deny, dismiss, or grant your appeal.� The Council will review the ALJ’s decision only if it finds present one of the reasons for review listed in the regulations at� 20 C.F.R. ' 404.970.

If the Medicare Appeals Council decides to review your case, it may change the parts of the ALJ’s decision that you agree with.� The Council may adopt, change, or reverse the ALJ’s decision, in whole or in part, or it may send the case back to an ALJ for further action.� The Medicare Appeals Council may also dismiss the appeal to the ALJ.

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