Administrative Law Judge Request Form Changes
Author: Suzy Harvey
Effective January 1, 2017, Medicare replaced form, “Request for Medicare Hearing by an Administrative Law Judge - CMS-20034 A/B,” with, “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100.” In addition, the form OMHA-100A is to be used as an attachment to identify multiple beneficiaries associated with a single request for an ALJ hearing or dismissal.
Both OMHA forms are used in the third level of the Medicare appeals process for claims and services denied by Medicare following a medical review. When a claim is requested for review by a Medicare Administrative Contractor (MAC) and a determination has been made to downcode or deny the claim, providers have a right to appeal the Medicare coverage and payment decisions.
The five levels in the Medicare Part A and Part B appeals process are:
First Level: Redetermination by a MAC but completed by a different reviewer
Second Level: Reconsideration by a Qualified Independent Contractor
Third Level: Hearing by an ALJ in the Office of Medicare Hearings and Appeals
Fourth Level: Review by the Medicare Appeals Council
Fifth Level: Judicial review in federal district court
Click here for detailed information and downloadable copies of the forms used at each appeal level.
Contact your BKD advisor for more information on the Medicare medical review and appeals process.