Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®.

If an ALJ issued a dismissal order 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) dismissal, 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 dismissal.   

If the Medicare Appeals Council does not review the ALJ’s dismissal on the appeal of a party or at the request of the Medicare agency, the last contractor determination is binding.

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 dismissal with your appeal.  

How to File an Appeal

You must file an appeal within 60 days after you receive the ALJ’s dismissal order.  The Medicare Appeals Council will assume that you received the ALJ’s dismissal order 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 dismissal 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 grants your appeal, it may send the case back to an ALJ for further action.  It may also issue a decision in your case. 

HHS Home | Questions? | Contact HHS | Accessibility | Privacy Policy | FOIA | Disclaimers

The White House | USA.gov | Helping America's Youth | HHS Archive

U.S. Department of Health & Human Services · 200 Independence Avenue, S.W. · Washington, D.C. 20201