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OMHA-100 FORM OMHA-100

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR ADMINISTRATIVE LAW JUDGE (ALJ)
HEARING OR REVIEW OF DISMISSAL
Section 1: Which Medicare Part are you appealing (if known)? (Check one)
Part A
Part B
Part C (Medicare Advantage) or Medicare Cost Plan Part D (Prescription Drug Plan)
Section 2: Which party are you, or which party are you representing? (Check one)
The Medicare beneficiary or enrollee, or a successor (such as an estate), who received or requested the items or services being
appealed, or is appealing a Medicare Secondary Payer issue.
The provider or supplier that furnished the items or services to the Medicare beneficiary or enrollee, a Medicaid State agency, or an
applicable plan appealing a Medicare Secondary Payer issue.
Other. Please explain:
Section 3: What is your (the appealing party's) information? (Representative information in next section)
Name (First, Middle Initial, Last)
Firm or Organization (if applicable)
Address where appeals correspondence should be sent City State ZIP Code
Telephone Number Fax Number E-Mail
Section 4: What is the representative's information? (Skip if you do not have a representative)
Name
Firm or Organization (if applicable)
Mailing Address City State ZIP Code
Telephone Number Fax Number E-Mail
Did you file an appointment of representation (form CMS-1696)
or other documents authorizing your representation at a prior
level of appeal?
No.
Please file the document(s) with this request.
Yes
Section 5: What is being appealed? Submit a separate request for each Reconsideration or Dismissal that you wish to appeal. If the
appeal involves multiple beneficiaries or enrollees, use the multiple claim attachment (OMHA-100A).
Name of entity that issued the Reconsideration or Dismissal (or
attach a copy of the Reconsideration or Dismissal)
Reconsideration (Medicare Appeal or Case) Number (or attach a
copy of the Reconsideration or Dismissal)
Beneficiary or Enrollee Name Health Insurance Claim Number
Beneficiary or Enrollee Mailing Address City State ZIP Code
What item(s) or service(s) are you appealing? (N/A if appealing a Dismissal) Date(s) of service being appealed (if applicable)
Supplier or Provider Name (N/A for Part D appeals)
Supplier or Provider Mailing Address (N/A for Part D appeals)
Supplier or Provider Telephone Number (N/A for Part D appeals)
City State ZIP Code
Section 6: For appeals of prescription drugs ONLY (Skip for all other appeals)
Part D Prescription Drug Plan Name
What drug(s) are you appealing?
Are you requesting an expedited hearing?
(An expedited hearing is only available if your appeal is not solely
related to payment (for example, you do not have the drug) and
applying the standard time frame for a decision (90 days) may
jeopardize your health, life, or ability to regain maximum function)
No.
Yes. On a separate sheet, please explain or have
your prescriber explain why applying the standard
time frame for a decision (90 days) may jeopardize
your health, life, or ability to regain maximum function.
OMHA-100 (12/19)
PAGE 1 OF 2
PSC Publishing Services (301) 443-6740.
EF
Section 7: Why do you disagree with the Reconsideration or Dismissal being appealed? (Attach a continuation sheet if necessary)
Section 8: Are you submitting evidence with this request, or do you plan to submit evidence?
I am not planning to submit evidence at this time. (Skip to Section 9, below)
I am submitting evidence with this request.
I plan to submit evidence. Indicate what you plan to submit and when you plan to submit it:
Was the evidence already
submitted for the matter that
you are appealing?
No. Part A and Part B appeals only. If you are a provider or supplier, or a provider or supplier that
is representing a beneficiary, you must include a statement explaining why the evidence is being
submitted for the first time and was not submitted previously.
Yes.
Section 9: Is there other information about your appeal that we should know?
Are you aggregating claims to meet the amount in controversy requirement? (If yes, attach your
aggregation request. See 42 C.F.R. § 405.1006(e) and (f), and 423.1970(c) for request requirements.)
No Yes
Are you waiving the oral hearing before an ALJ and requesting a decision based on the record? (If
yes, attach a completed form OMHA-104 or other explanation. N/A if requesting review of a dismissal.)
No Yes
Does the request involve claims that were part of a statistical sample? (If yes, please explain the
status of any appeals for claims in the sample that are not included in this request.)
No
Yes
Section 10: Certification of copies sent to other parties (Part A and Part B appeals only)
If another party to the claim or issue that you are appealing was
sent a copy of the Reconsideration or Dismissal, you must send a
copy of your request for an ALJ hearing or review of dismissal to
that party.
Indicate the party (or their representative) to whom and address
where you are sending a copy of the request, and when the copy
will be sent (attach a continuation sheet if there are multiple
parties).
Name of Recipient
Mailing Address
City State ZIP Code
Date of Mailing
Check here if no other parties were sent a copy of the Reconsideration or Dismissal.
Section 11: Filing instructions
Your appealed claim must meet the current amount in controversy requirement to file an appeal. See the Reconsideration or Dismissal or
visit www.hhs.gov/omha
for information on the current amount in controversy. Send this request form to the entity in the appeal instructions
that came with your reconsideration (for example, requests for hearing following a Part C reconsideration are generally sent to the entity
that conducted the reconsideration). If instructed to send to OMHA, use the addresses below.
Beneficiaries and enrollees, send your
request to:
OMHA Central Operations
Attn: Beneficiary Mail Stop
1001 Lakeside Ave., Suite 930
Cleveland, Ohio 44114-1158
For expedited Part D appeals, send your
request to:
OMHA Central Operations
Attn: Expedited Part D Mail Stop
1001 Lakeside Ave., Suite 930
Cleveland, Ohio 44114-1158
All other appellants, send your
request to:
OMHA Central Operations
1001 Lakeside, Suite 930
Cleveland, Ohio 44114-1158
We must receive this request within 60 calendar days after you received the Reconsideration or Dismissal that you are appealing. We will
assume that you received the Reconsideration or Dismissal 5 calendar days after the date of the Reconsideration or Dismissal, unless you
provide evidence to the contrary. If you are filing this request late, attach a completed form OMHA-103 or other explanation for the lat
e filing.
PRIVACY ACT STATEMENT
The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and
sections 1852(g)(5), 1860D-4(h)(1), 1869(b)(1), and 1876 of Title XVIII). The information provided will be used to further document
your appeal. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested
information may affect the determination of your appeal. Information you furnish on this form may be disclosed by the Office of
Medicare Hearings and Appeals to another person or governmental agency only with respect to the Medicare Program and to comply
with Federal laws requiring the disclosure of information or the exchange of information between the Department of Health and Human
Services and other agencies.
If you need large print or assistance, please call 1-855-556-8475
OMHA-100 (12/19)
PAGE 2 OF 2
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OMHA-100 FORM OMHA-100

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Completed 16 February 2020

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