Administrative Law Judge Hearing-Third Level of Appeal

If the claimant is still dissatisfied with the QIC or Hearing Officer’s decision and the amount in
controversy is $120, the claimant is entitled to a hearing before an Administrative Law Judge
(ALJ). Claimants requesting an ALJ hearing must, by law, do so in writing within 60 days of the
date of the QIC decision.

All Requests for Administrative Law Judge (ALJ) hearings are now handled by the office of
Medicare Hearings and Appeals. The ALJs determine what type of ALJ hearing to conduct. The
OMHA field offices are equipped to conduct hearings via videoconferencing, by telephone or inperson.
The ALJ may also issue a decision on the record without the appearance of any parties of
the decision is fully favorable to the appellant.

If a party is filing a request for an ALJ hearing to appeal a QIC reconsideration, he or she may
either complete Form CMS-20034A/B, Request for Medicare Hearing by An Administrative Law
Judge, which is available at
http://www.cms.hhs.gov/cmsforms/downloads/cms20034ab.pdf
or by submitting a written and signed request that includes the following information;

• Name, address and Medicare HIC number of the beneficiary;
• Name and address of the claimant when it is not the beneficiary;
• Name and address of any designated representatives;
• Document control number assigned to the appeal by the QIC, if any;
• Dates of Service for the items or services at issue;
• Reason for disagreeing with the QIC reconsideration ( or Part B hearing officer decision)
• Statement of any additional evidence to be submitted and the date it will be submitted

If a party is filing a request for an ALJ hearing to appeal a hearing officer decision, he or she may
either complete Form CMS-5011 A/B, Request for Medicare Hearing by an Administrative Law
Judge, which is available on the CMS website or submit a written request that includes the
information noted above.

Send your request to the following address:
The Office of Medicare Hearings and Appeals (OMHA)
Health and Human Services
27 Technology Drive, Suite 100
Irvine, CA 92618-2364