OMHA-100 · Office of Medicare Hearings and Appeals
Request for Administrative Law Judge hearing or review of dismissal. Third-level appeal for Medicare claim denials when amount in controversy meets threshold.
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OMHA Online Filing
https://www.hhs.gov/omha/File electronically through the OMHA case management system.
Mail to the OMHA field office assigned to your jurisdiction
Office of Medicare Hearings and Appeals 1700 N. Moore Street, Suite 1800 Arlington, VA 22209
Fax to OMHA
Fax: 855-462-5382
Filing Deadline
60 days from the date of the IRE or QIC reconsideration decision.
90 days from receipt of the request. Administrative backlog may extend this. Expedited hearings available for urgent cases.
An Administrative Law Judge (ALJ) will be assigned to your case. You will receive a hearing notice. Hearings may be conducted in person, by video teleconference, or by telephone.
CMS-20027 · CMS
First-level appeal for Original Medicare (Part A/B) claim denials. Must be filed within 120 days of the initial determination.
DAB-101 · HHS Departmental Appeals Board
Request for Medicare Appeals Council review. Fourth-level appeal after an Administrative Law Judge decision.
CMS-40B · CMS
Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.
CMS-L564 · CMS
Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.
CMS-10797 · CMS
Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.
CMS-10798 · CMS
Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.
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