Appeals - Level 3: Hearing before an Administrative Law Judge (ALJ)

A hearing before an Administrative Law Judge (ALJ) allows you to present your appeal to a new person who'll independently review the facts of your appeal before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, or in some cases, in person. You can also ask the ALJ to make a decision without a hearing.

To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2013, the required amount is $140. The "Medicare Reconsideration Notice" will include a statement that tells you if your case meets the minimum dollar amount. However, it's up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.

To request a hearing, follow the directions on the "Medicare Reconsideration Notice" you got from the QIC in level 2 to request a hearing before an ALJ. You must send your request to the appropriate Office of Medicare Hearings and Appeals (OMHA) field office. The address of the appropriate field office is listed in the QIC's reconsideration notice. You can file a request for a hearing in one of the following ways:

  1. Fill out a "Request for Hearing by an Administrative Law Judge" form.
  2. Submit a letter to the OMHA office that will handle your ALJ hearing that includes:
    • Your name, address, and Medicare number. If you've appointed a representative, include your representative's name and address.
    • The document control number included on the QIC reconsideration notice, if any.
    • The dates of service for the items or services you're appealing. See your MSN or reconsideration notice for this information.
    • An explanation of why you disagree with the reconsideration decision.
    • Any information that may help your case. If you can't include this information with your request, include a statement explaining what you plan to submit and when you will submit it.

You can find more information about the ALJ hearing process at the Office of Medicare Hearings and Appeals website, call 1-800-MEDICARE.

In most cases, the ALJ will send you a written decision within 90 days of getting your request. If the ALJ doesn't issue a timely decision, you may ask the ALJ to move your case to the next level of appeal.

If you disagree with the ALJ's decision in level 3, you've 60 days after you get the ALJ's decision to request a review by the Medicare Appeals Council (Appeals Council).