Medicare ALJ Hearing (Level 3 Appeal): Filing, Evidence, Decision

A Medicare ALJ hearing is the third level of the Medicare appeals process and the first time an independent judge, rather than a Medicare contractor, looks at your claim. It’s run by the Office of Medicare Hearings and Appeals (OMHA), an independent office within the Department of Health and Human Services with no connection to the contractors who denied your claim at the earlier levels.¹ To get one in 2026, at least $200 must be in dispute, and you have to file the request in writing within 60 days of receiving your second-level reconsideration decision.²

Do You Qualify

Any party to the earlier reconsideration can request the hearing: the beneficiary, a provider or supplier, or another entity that participated at the prior level.¹ Two conditions decide whether your request can move forward: the dollar amount in dispute and the filing deadline.

The $200 Amount in Controversy

Your dispute has to meet a minimum dollar figure called the Amount in Controversy. For 2026 that figure is $200.² It adjusts every year based on the medical care component of the consumer price index, so verify the current threshold if you’re reading this later.³ A single claim under $200 isn’t automatically out. You can combine multiple claims to reach the threshold if they share common issues of law or fact.

The 60-Day Filing Deadline

You have 60 days from the day you receive the reconsideration decision to file. OMHA presumes you received the notice five days after the date printed on it unless you can prove otherwise, so in practice your clock starts on day six.⁴

Miss the deadline and your request will be dismissed unless you can show good cause for filing late. The regulation borrows the good-cause standards used at the reconsideration level, which typically cover serious illness, a death in the family, destruction of important records, or a delay in receiving the decision notice.⁵ Explain your reason in writing when you file.

How to File the Request

The request must be in writing. It has to include the beneficiary’s name, address, and Medicare number; the Medicare appeal number from the reconsideration decision; the dates of service; and the reasons you disagree with the reconsideration. If you plan to submit new evidence, add a statement describing what it is and when you’ll send it.⁵

OMHA publishes an optional Form OMHA-100 that collects every required field in one place, but it isn’t mandatory. A letter with the same information works just as well.⁶ The form is available on the HHS website.⁷

Filing Online, by Mail, or by Fax

OMHA runs an electronic appeal portal that accepts requests online, with ID.me multi-factor authentication and a valid photo ID. It’s the fastest route. Some appeal types cannot use it, though: Part A Quality Improvement Organization decisions, Social Security Administration appeals, Medicare Secondary Payer claims, Medicare Advantage (Part C) appeals, and Part D prescription drug appeals all have to go by mail or fax.⁸

For mailed filings, the correct address is listed on your reconsideration notice. Certified mail with a return receipt is worth the small cost so you can document your filing date. Federal rules also require you to notify every other party that participated in the reconsideration that you’ve asked for an ALJ hearing. Keep proof of that notification with your records.

Submitting New Evidence

If you want the judge to consider evidence that wasn’t in front of the Qualified Independent Contractor during the second-level review, you’ll usually need to show good cause for not submitting it earlier.⁹ Good cause covers a few common situations: the evidence relates to an issue that wasn’t identified as key until after the reconsideration; you made reasonable efforts to get it earlier but couldn’t; or you actually did submit it to the contractor and it wasn’t considered.

There’s an important exception. If you’re an unrepresented beneficiary, meaning you’re handling your own appeal without a provider, supplier, or attorney, the good-cause requirement for new evidence doesn’t apply to you. You can submit new documentation freely.

New evidence aside, include copies of the reconsideration decision and your supporting medical records with your filing. A complete record helps OMHA move your case along.

Getting Help or a Representative

You can represent yourself, and many beneficiaries do. You can also appoint someone else, whether an attorney, a family member, a friend, or a patient advocate. To make the appointment official, complete CMS Form 1696, which requires signatures from both you and your representative and stays valid for one year from the date it’s signed.¹⁰

Providers and suppliers who furnished the items or services in dispute cannot charge you for representation. An attorney or other representative who wants to charge a fee for work on the hearing has to petition OMHA for fee approval.¹⁰

If you’d rather not hire anyone but want guidance, your State Health Insurance Assistance Program (SHIP) offers free Medicare counseling and can point you toward legal resources. Reach your local SHIP office through 877-839-2675.

What the Hearing Looks Like

Most hearings happen by phone or video. In-person hearings are available in limited circumstances when the judge decides physical presence is necessary. If you’re an unrepresented beneficiary, the judge will generally direct that your appearance be by video rather than telephone.

The judge identifies the issues, manages testimony, and asks questions to fill gaps in the record. You or your representative can testify, explain why the claim should be covered, and bring in witnesses like your treating physician or a billing specialist. This is the point in the process where you can address the reasons for denial in a way that paperwork alone often can’t.

You can skip the oral hearing by submitting Form OMHA-104 with your request. In that case, the judge, or an attorney adjudicator (a non-judge decision-maker at OMHA with similar authority), decides the case on the written record.¹

CMS or a Medicare contractor can also take part, either as a limited participant or as a full party with broader rights to call witnesses and cross-examine yours.¹¹ When the beneficiary is unrepresented, CMS and contractors generally cannot elect party status, which is one protection built in for people appealing on their own.

The Decision and How Long It Takes

The judge generally has 90 calendar days from the date OMHA receives your request to issue a decision.¹² Written decisions come in three flavors: fully favorable (every issue decided in your favor), partially favorable (some issues yours, some not), or unfavorable (none in your favor).¹³

For fiscal year 2026 through December 2025, OMHA reports that about 22.8% of decisions were fully favorable to the appellant, 1.7% partially favorable, and 58.5% unfavorable.¹⁴ Roughly one in four appellants gets at least some relief.

If 90 days pass with no decision, you don’t have to keep waiting. You can file a written request to escalate the appeal to the Medicare Appeals Council, which is the fourth level of review. If you don’t escalate, your case simply stays open at OMHA until the judge decides it.¹²

If You Lose

An unfavorable or partially favorable decision isn’t the end. The fourth level is review by the Medicare Appeals Council, part of the HHS Departmental Appeals Board. You have 60 days from receiving the ALJ decision to request Council review, with the same five-day receipt presumption. There is no Amount in Controversy requirement for the Council, so even small-dollar claims can proceed.¹⁵ Send a copy of your review request to the other parties who received the ALJ decision.

Beyond the Council sits a fifth level: judicial review in federal district court. That step requires at least $1,960 in controversy for 2026.²

1
Centers for Medicare & Medicaid Services. Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals
2
Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026
3
eCFR. 42 CFR 405.1006 – Amount in Controversy Required for an ALJ Hearing and Judicial Review
4
U.S. Department of Health and Human Services. FAQs – Requesting an ALJ Hearing
5
eCFR. 42 CFR 405.1014 – Request for ALJ Hearing or Review of a QIC Dismissal
6
U.S. Department of Health and Human Services. Tips for Filing a Request for ALJ Hearing or Review of Dismissal
7
Department of Health and Human Services. Form OMHA-100 – Request for Administrative Law Judge Hearing or Review of Dismissal
8
U.S. Department of Health and Human Services. Filing an Appeal
9
eCFR. 42 CFR 405.1028 – Review of New Evidence by an ALJ or Attorney Adjudicator
10
Centers for Medicare & Medicaid Services. Appointment of Representative – CMS-1696
11
eCFR. 42 CFR 405.1010 – When CMS or Its Contractors May Participate in the Proceedings on a Request for an ALJ Hearing
12
eCFR. 42 CFR 405.1016 – Time Frames for Deciding an Appeal of a QIC Reconsideration or Escalated Request for a QIC Reconsideration
13
U.S. Department of Health and Human Services. OMHA Case Processing Manual – Chapter 16 Decisions
14
U.S. Department of Health and Human Services. Decision Statistics
15
Centers for Medicare & Medicaid Services. Fourth Level of Appeal: Review by the Medicare Appeals Council