Form | Description |
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Requests for Medicare Hearing by an Administrative Law Judge (ALJ) (For a reconsideration/fair hearing determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) Form CMS 5011 A/B [PDF - 88KB] | This form is used to request an Administrative Law Judge (ALJ) review of a reconsideration/fair hearing determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO). Remember, the remaining amount in controversy must meet the current minimum for an ALJ review. |
Requests for Medicare Hearing by an Administrative Law Judge (ALJ) (For a reconsideration determination issued by a Qualified Independent Contractor (QIC)) Form CMS 20034 A/B [PDF - 85KB] | This form is used to request an Administrative Law Judge (ALJ) review of a reconsideration determination issued by a Qualified Independent Contractor (QIC). Remember, the remaining amount in controversy must meet the current minimum for an ALJ review. |
Request for Administrative Law Judge (ALJ) to Review Dismissal by the Qualified Independent Contractor Form HHS-725 [PDF - 36KB] | This form is used to request an Administrative Law Judge (ALJ) review of a dismissal of your request for an appeal. Remember, the remaining amount in controversy must meet the current minimum for an ALJ review. |
Extension Request to File a Request for an Administrative Law Judge Hearing Form HHS 727 [PDF - 26KB] | This form is used to request an extension to submit your request for an Administrative Law Judge (ALJ) hearing with the Office of Medicare Hearings and Appeals (OMHA) beyond the normal 60 calendar days. The ALJ has the discretion to accept or deny your request based on your good cause explanation as to why you are unable to submit your request within the 60 days. |
Withdrawal of Request for an Administrative Law Judge (ALJ) Hearing Form HHS-730 [PDF - 36KB] | This form is used to withdraw your request for an Administrative Law Judge (ALJ) hearing before the Office of Medicare Hearings and Appeals (OMHA). If you file this form, your appeal will be dismissed by the ALJ if no other party has filed a valid Request for ALJ Hearing. Your request will not be honored if the ALJ has already issued a decision. |
Waiver of Right to An Administrative Law Judge (ALJ) Hearing Form HHS-723 [PDF - 36KB] | This form is used to waive your right to have an oral hearing before the Administrative Law Judge (ALJ). If you submit this form, your case will be decided on the record without an oral hearing. |
Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ) Hearing Form HHS-731 [PDF - 36KB] | This form is used to withdraw your prior decision to waive your right to have a hearing before the Administrative Law Judge (ALJ). Your request will be honored only if the ALJ has not yet issued a decision. The ALJ may extend the decision-making time frame beyond the normal period in order to schedule and hold the hearing. |