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How to Request an ALJ Hearing

What You Can Do If You Do Not Agree with C2C’s Decision

You can request an Administrative Law Judge (ALJ) hearing with the Office of Medicare Hearings and Appeals (OMHA). If you request an ALJ hearing, an ALJ or attorney adjudicator from OMHA will decide your case. You can learn more about the ALJ hearing process by visiting the Centers for Medicare & Medicaid Services (CMS) Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA) webpage.

An ALJ hearing is free of charge and can be done over the phone. You are not required to attend the hearing in person and there is no cost to you for this service.

To qualify for an ALJ hearing, the amount of money at stake in your appeal must satisfy the amount in controversy requirement. The amount in controversy is adjusted each year and is available on CMS’ Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA) webpage.

How to Request an ALJ Hearing

A Reconsideration Decision Letter from the C2C provides the full instructions about how to request an ALJ hearing. To ask for an ALJ hearing, fill out the ALJ Hearing Request Form  and send it to C2C. Your ALJ Hearing Request Form must be received by C2C within 60 calendar days of the day you received your reconsideration decision letter. Your receipt of this letter is presumed to be five (5) days after the date stated above unless you can show you did not receive the notice within that time. If your request for ALJ hearing is being filed late, you must explain why your request is being filed late. More information on late filing is available on CMS’ Medicare Appeals Good Cause for Late Filing webpage.

The written request must contain all of the following information:

  • The name, address and Medicare number of the beneficiary whose claim is being appealed, as well as the beneficiary's telephone number if the beneficiary is the appealing party and not represented
  • The name, address and telephone number of the appellant if the appellant is not the beneficiary
  • The name, address and telephone number of the authorized or appointed representative, if there is one
  • The Medicare appeal number or document control number, if there is one, assigned to the Qualified Independent Contractor (QIC) reconsideration or dismissal notice being appealed
  • The dates of service of the claim(s) being appealed
  • The reasons the appellant disagrees with the C2C's reconsideration or other determination being appealed 

If you prefer not to participate in the hearing, you may have an on-the-record review. This is also free of charge and is based on the administrative records and case file sent to OMHA by C2C. To have an on-the-record review, also fill out the Waiver of Right to an Administrative Law Judge (ALJ) Hearing form (i.e., Form OMHA-104) linked below and send it to C2C with your Request for ALJ Hearing.

Form OMHA-104 [PDF]

Form OMHA-104 (in Spanish) [PDF]

Form OMHA-104 (Large Print in Spanish) [PDF]

What to Expect

C2C will then send your ALJ Hearing Request Form and the case file used to decide your appeal to OMHA. Once this is done, any further communications regarding your appeal will come directly from OMHA. After you file an appeal, you may check your appeal’s status via the Appeals Status Lookup webpage on the OMHA website.

  • OMHA will schedule your hearing and tell you the time and place of the hearing.
  • During your hearing, you will provide information about your case.
    • Your health plan may also have someone at the hearing to give information.
    • You can include anyone to speak for you or help you. This person does not have to be a lawyer. For example, it may be a friend, family member or doctor.
  • The ALJ or attorney adjudicator will make a decision based on your case file and the information provided during the hearing.
  • OMHA will send the written decision to you, your health plan and to C2C.
  • If the ALJ or attorney adjudicator agrees with you, C2C will send a letter to your health plan telling them to pay or provide for your health care.