Your Medicare claim was denied and you lost your Level 1 appeal (request for reconsideration or redetermination) and Level 2 appeal (review by an independent reviewer). You have carefully reviewed the Level 2 decision for directions on how, when, and where to request a Level 3 administrative law judge review. If you correctly followed the instructions for filing a request for hearing at the Office of Medicare Hearings & Appeals, this is what you can expect next.
The Office of Medicare Hearings and Appeals, referred to as “OMHA,” is staffed with administrative law judges, or ALJs, who hear Level 3 Medicare appeals. OMHA is a part of the U.S. Department of Health & Human Services.
If your request has been correctly and timely filed, and you’ve met the minimum required dollar amount for a Level 3 hearing ($160 in 2017), you will receive a notice from the Office of Medicare Hearings and Appeals advising you of the date, location, and time of your hearing.
You should receive this Notice of Hearing at least 20 days before the hearing. You must fill out and return a “Response to Notice of Hearing Form” to the ALJ listed on the Notice of Hearing within the time limit set forth on the notice.
You should carefully read and follow the instructions in the Notice of Hearing from the ALJ. You can contact the staff at the OMHA field office identified in the hearing notice for assistance. If you call the staff, they can give you the latest information on:
You should consider whether to obtain legal advice before requesting an ALJ hearing. You can have an attorney represent you, but it is not required at the hearing. You can also appoint a personal representative, such as a spouse, friend, caregiver, or patient advocate to appear on your behalf. If you wish to appoint a representative, do so as soon as possible and be sure to ask the ALJ’s field office staff for assistance in completing and submitting the proper forms for appointing a representative.
To arrange a free consultation with a lawyer who handles Medicare and Social Security disability appeals, visit Nolo's lawyer directory.
The ALJ hearing may occur in one of three ways:
In-person hearings. You must request an in-person hearing in writing and you must submit an explanation as to why the hearing needs to be in-person. The ALJ will grant your request if “good cause” exists for you to appear in person rather than by VTC or telephone. Even if you don't request an in-person hearing, the ALJ might decide that the circumstances in your case warrant an in-person hearing.
Video conferences. It is very common for the ALJ to set up a VTC from a location near your home. You will be asked to go to the VTC location, which has private rooms with video cameras and televisions that allow you and the ALJ (who is at the field office location) to see and talk to each other. The equipment is set up by an on-site technician, but the technician is not otherwise present during the hearing and cannot hear your conversation with the ALJ. Your representative, or someone else you want to accompany you, and your witnesses may attend the VTC location. The OMHA field office staff will work with you to find a convenient VTC location near your home.
Telephone hearings. A telephone hearing also may be utilized in certain cases, for the convenience of the parties.
On-the-record decisions. In some cases, you may be notified that the ALJ has decided to forgo a hearing altogether and has decided the case “on-the-record,” when the evidence in your claim files supports a decision in your favor without the need to ask you or any witnesses any questions.
The ALJ will introduce himself or herself and any other persons participating in your hearing, such as field office staff assisting in the hearing process, witnesses, doctors or other experts the ALJ has asked to attend, and anyone else the ALJ deems necessary and proper to attend the hearing. You can also invite witnesses to testify on your behalf. You and the witnesses who intend to testify will be placed under oath.
The ALJ will explain the issues in your case. The ALJ will ask questions of you and the witnesses, and you and the witnesses will answer them under oath. You or your lawyer will be able to ask questions of any witnesses appearing at your hearing.
The ALJ will make an impartial review of the facts and make a determination on the credibility of the evidence, including the testimony from the hearing and the documents contained in your claim file, and the applicable rules in reaching a decision.
The ALJ will make an audio recording of the hearing.
If you change any of your contact information, such as your telephone number or address, notify the ALJ assigned to your case immediately. Also, contact the ALJ immediately if you cannot attend the scheduled hearing or if you object to the time or place set for your hearing. If you have good cause for changing the time or place of the hearing, it will be rescheduled. If you fail to appear at your hearing without a good reason, also called “good cause,” your case may be dismissed by the ALJ. As always, if you have any questions or concerns about the hearing process, contact your OMHA field office for assistance.
If you need help filing your appeal you might want to contact your State Health Insurance Assistance Programs (SHIP) (https://shipnpr.shiptalk.org), California Health Advocates (HICAP) (http://www.cahealthadvocates.org), or the Center for Medicare Advocacy (www.medicareadvocacy.org).