Level 3 — Part A Administrative Law Judge (ALJ) Hearing

Medicare Claims Processing Manual (Pub 100-04 Ch. 29 §330)

An Administrative Law Judge (ALJ) hearing is the third level of appeal.   If you are dissatisfied with the reconsideration decision, and the amount in controversy (denied amount) is $130 or more for requests made in 2010, you have the right to a hearing by an ALJ. You may attend this hearing in person, send a representative, or have the ALJ review the record.  More than one beneficiary’s claim can be used to meet the $130 amount in controversy. 

How to Request an ALJ Hearing

A written request for an ALJ hearing must be submitted to the entity specified in the QIC’s reconsideration decision.  The request must be made within 60 days of the date of the QIC’s reconsideration decision. 

The ALJ hearing request may be submitted in writing either on the Request for Medicare Hearing by an Administrative Law Judge or a written request that includes the following items.

• The beneficiary’s name, address, and Medicare health insurance claim number;
• The name and address of the appellant, when the appellant is not the beneficiary;
• The name and address of the designated representative, if any;
• The document control number assigned to the appeal by the QIC, if any;
• The reasons you disagree with the QIC’s reconsideration.

The ALJ has 90 days to process their decision.  A letter will be mailed to you with the ALJ decision.

• Written Assurance Letters

Page last updated: May 13, 2010

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