DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR REVIEW OF A REMAND
Instructions: If you are a party to an appeal requesting a hearing before an Administrative Law Judge, or if you represent CMS or a
CMS contractor, or a Part D plan sponsor, and you have received notice of a remand from the Office of Medicare Hearings and
Appeals (OMHA) that you believe was not authorized by the governing regulations at 42 C.F.R. section 405.1056 or 423.2056, you
may request that the OMHA Chief Administrative Law Judge or designee review the remand. Requests for review of a remand must
be filed within 30 calendar days of receiving notice of the remand.
Complete this form and send it to OMHA Central Operations, Attention: Remand Review Mail Stop (visit
www.hhs.gov/omha or call
the number at the bottom of this form for the full mailing address). Upon receipt of a valid request, the OMHA Chief Administrative
Law Judge or a designee will review the remand to determine if it was authorized by the governing regulations. If it is determined that
the remand was not authorized, the remand order will be vacated and the appeal will return to OMHA for further proceedings on the
request for hearing before an Administrative Law Judge. If the remand order is not vacated, the remand order will remain in effect.
You may not request review of a remand issued on a request to review the dismissal of a request for reconsideration.
Section 1: What is the information for the remanded appeal?
OMHA Appeal Number OMHA Adjudicator Name Date of Notice of Remand
Section 2: What is the information for the party or entity point of contact requesting review? (Representative information
in next section)
Name (First, Middle initial, Last) Firm or Organization (if applicable)
Telephone Number
Section 3: What is the representative's information? (Skip if you do not have a representative)
Name
Firm or Organization (if applicable)
Telephone Number
Section 4: Explain why you are requesting review. Although not required, you may provide an explanation or argument why you
believe that the remand was not authorized by the governing regulations at 42 C.F.R. section 405.1056 or 423.2056.
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-107 (06/17)
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PSC Publishing Services (301) 443-6740.
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