Administrative Law Judge (ALJ) Hearing or Attorney Adjudicator

330 - Administrative Law Judge (ALJ) Hearing or Attorney Adjudicator Review at the Office of Medicare Hearings and Appeals (OMHA) - The Third Level of Appeal (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) A party to a QIC reconsideration may request a hearing before an ALJ if the party files a written request for an ALJ hearing within 60 days after receipt of the notice of the QIC’s reconsideration and the amount in controversy requirement is met*. A party who files a timely appeal before a QIC and whose appeal continues to be pending before a QIC at the end of the QIC’s decision-making timeframe has a right to a hearing before an ALJ if the party files a written request with the QIC to escalate the appeal to the ALJ level after the adjudication period expires and the QIC does not issue a final action within 5 days of receiving the request for escalation. A party wishing to escalate an appeal must also meet the amount in controversy requirement*. A party to a QIC’s dismissal of a request for reconsideration has a right to have the dismissal reviewed by an ALJ or attorney adjudicator if the party meets the amount in controversy requirement*. *See §250 for AIC information. The current amount in controversy requirements can be found on the CMS.gov claims appeals webpage: http://www.cms.gov/Medicare/Appeals-and- Grievances/OrgMedFFSAppeals/Downloads/AppealsProcessFlowchart-FFS.pdf