Industry Insights

Administrative Law Judge Request Form Changes

April 2017
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

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.

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