OMHA administers the nationwide Administrative Law Judge (ALJ) hearing program for appeals arising from individual claims for Medicare coverage and payment for items and services furnished to beneficiaries (or enrollees) under Medicare Parts A, B, C and D. OMHA also hears appeals arising from claims for entitlement to Medicare benefits and disputes of Part B and Part D premium surcharges. OMHA generally conducts the third level of a five-level appeals process, and operates separately from the other agencies involved in the Medicare claims appeal process.
OMHA is responsible for Level 3 of the Medicare claims appeal process; certain Medicare entitlement appeals; Part B and Part D premium appeals. It was created by the Medicare Modernization Act of 2003 to simplify the appeals process and make it more efficient. During an appeal, an OMHA Administrative Law Judge or attorney adjudicator conducts a new (“de novo”) review of an appellant’s case and issues a decision based on the facts and the law.
The Chief Administrative Law Judge leads the entire agency, which consists of six field offices and a headquarters office. Each field office includes many Administrative Law Judges and attorney adjudicators who are overseen by an Associate Chief Administrative Law Judge. Appeals are assigned to these adjudicators by a Centralized Docketing Division in accordance with standardized procedures.
The entry point of the appeals process depends on the part of the Medicare program that covers the disputed benefit or whether the beneficiary is enrolled in a Medicare Advantage plan. Within OMHA, which is responsible for Level 3 claims appeals, if an individual disagrees with the Level 2 decision or dismissal, the individual may request that an OMHA adjudicator review the action.
This dataset includes ALJ Number, Appeal Category, Request and Requestor Type, Record Type and Date, Appeal Status, Hearing Type and much more.