DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
NOTICE OF INTENT TO PARTICIPATE IN PROCEEDINGS ON A
REQUEST FOR AN ADMINISTRATIVE LAW JUDGE (ALJ) HEARING
OR TO BE A PARTY TO AN ALJ HEARING
Instructions: CMS, a CMS contractor, or a Part D Plan Sponsor may use this form to elect (in Medicare Part A and Part B appeals) or
request (in Medicare Part D appeals) to be a participant in the proceedings on a request for an Administrative Law Judge (ALJ) hearing.
CMS or a CMS contractor may alternatively use this form to elect to be a party to an ALJ hearing on a Medicare Part A or Part B
appeal, if one is scheduled, unless the request for hearing was filed by an unrepresented beneficiary. The time frames for submission of
a valid election or request are set forth in 42 C.F.R. sections 405.1010, 405.1012, and 423.2010.
Complete this form and send it to the assigned OMHA adjudicator, or if an adjudicator has not yet been assigned, to OMHA Central
Operations, Attention: CMS and CMS Contractor Elections Mail Stop. You must also send a copy of this form to the parties who were
sent a copy of the notice of reconsideration or, if you are filing this form after receipt of a notice of hearing, any party that was sent a
copy of the notice of hearing. An ALJ or attorney adjudicator may determine that your election is invalid if it was not timely filed or not
sent to the correct parties. If the appellant requested an expedited hearing, your request to participate may be made orally.
Section 1: What is the OMHA appeal number or the reconsideration (Medicare appeal or case) number?
OMHA Appeal Number (if known) Reconsideration Number (if OMHA appeal number not known)
Note: If the appeal involves multiple claims and/or beneficiaries and you intend to be a party or participant with respect to some, but
not all, include a separate sheet listing the claims and/or beneficiaries for which you are filing this notice of intent.
Section 2: What is the contact information for the entity that is filing this notice of intent?
Name of CMS Office, Contractor, or Part D Plan Sponsor Point of Contact (POC)
Mailing Address
City State ZIP Code
POC Telephone Number POC Fax Number POC E-Mail
Section 3: Complete this section if you did not receive a notice of hearing.
(Skip to section 4 if you received a notice of hearing)
Date you were notified that a request for hearing was filed:
Note: Your notice of intent must be sent no later than 30 calendar days after notification that a request for hearing was filed, or within
2 calendar days after notification that a request for an expedited Part D hearing was filed.
Are you submitting a position paper and/or written testimony? (Check one)
Yes, with this form.
Yes, on a future date. (See 42 C.F.R. sections 405.1010, 405.1012, or 423.2010 for time frames for submission of position
papers, written testimony, and/or evidence.)
No, I do not intend to submit a position paper and/or written testimony.
Acknowledge the following by signing and dating below:
•
I certify that I am sending a copy of this notice of intent to the parties who were sent a copy of the notice of reconsideration. I
understand that the OMHA adjudicator may determine that my election or request is invalid if it is not timely filed or is not sent to
the correct parties.
•
I certify that I have provided, or will provide, a copy of all submitted position papers and/or written testimony to the appropriate
parties and within the time frames as set forth in 42 C.F.R. sections 405.1010, 405.1012, or 423.2010, as applicable. I
understand that failure to provide copies to the appropriate parties or to submit all items within the required time frames will
result in the submissions not being considered by the OMHA adjudicator.
POC Signature Date
Note: If an ALJ hearing is later scheduled and you intend to participate in the oral hearing or elect to be a party to the hearing, you
may resubmit the same form with section 4 completed after receiving the notice of hearing. The updated form must be sent to the
ALJ, with copies to the appropriate parties.
OMHA-105 (04/18) PAGE 1 OF 2
PSC Publishing Services (301) 443-6740.
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