Your Right to Appeal After A Reconsideration

If you requested reconsideration of an appeal, and do not agree with the decision, you may file another appeal. This next level of appeal is called an Administrative Law Judge (ALJ) hearing. At this hearing, you or your representative present your case before an Administrative Law Judge.

You must have at least $110 in dispute to file this appeal. The appeal can be combined with others to reach the $110 total if the other claims were appealed and decided within 60 days of the new request for an appeal and involve similar or related services.

How to Appeal

You must a request your appeal in writing. You must request the appeal within 60 days of receiving the reconsideration decision letter. Under special circumstances, you may ask for more time to make your request.

Your request must include:

The beneficiary's name, address, and Medicare health insurance claim number;
The name and address of the person appealing, if that person is not the beneficiary;
The name and address of the representative, if any;
The appeal number listed on the front page of the decision letter you received;
The dates of service;
The reasons you disagree with the decision;
All of the evidence you wish to submit and the date it will be submitted;
A statement that you have sent a copy of this request to the other parties to the appeal; and
If you are combining claims to meet the $110 amount, a list of the claims.

ALJ hearings are usually held by video teleconference (VTC) to make sure your hearing takes place, and your case is decided, as soon as possible. VTC hearings reduce travel time for you, ALJs, and witnesses. If you do not want a VTC hearing, you may ask for a hearing in person, which will be granted for good cause. Your request must be in writing. It must give a good reason why you don't want a VTC hearing. If your request for an in-person hearing is granted, a hearing will be held and a decision issued as soon as possible.

How to File Your Appeal

To request this level of appeal, send your request to:

OMHA Mid-West Field Office
BP Tower, Suite 1300,
200 Public Square
Cleveland, Ohio 44114-2316
Phone: 866-236-5089

Who May File an Appeal

You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.

If you want someone to act for you, you and your appointed representative must sign, date and send us a statement naming that person to act for you. Call 1-800-MEDICARE to learn more about how to name a representative.

Help With Your Appeal

If you want help with an appeal, or if you have questions about Medicare, you can ask a friend or someone else to help you. You can also contact your State Health Insurance Assistance Program (SHIP). Call 1-800-MEDICARE (1-800-633-4227) for information on how to contact your local SHIP. Your SHIP can answer questions about payment denials and appeals.

Other Important Information

If you want copies of statutes, regulations, policies, and/or manual instructions that IPRO used to arrive at an appeal decision, please send your request and a copy of the decision letter to:

IPRO
Medicare/Federal Health Care Assessment
1979 Marcus Avenue
Lake Success, NY 11042

If you need more information or have any questions, please call us at 1-800-331-7767.

Other Resources to help you: 1-800-MEDICARE (1-800-633-4227); TTY/TDD: 1-800-486-2048.