DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
FILING OF NEW EVIDENCE
Instructions: If you have new evidence to submit, complete this form and include it with your request for an ALJ hearing (form
OMHA-100), or if you have already filed your request for an ALJ hearing or if you are a party but not the appellant, send this form to
the assigned Office of Medicare Hearings and Appeals (OMHA) adjudicator (visit
www.hhs.gov/omha and use the appeal status
lookup tool to find your assigned adjudicator). If an adjudicator has not yet been assigned, send this form to OMHA Central
Operations, Attention: New Evidence Mail Stop (visit
www.hhs.gov/omha
or call the number at the bottom of this form for the full
mailing address).
Unless you are an unrepresented beneficiary or enrollee, any additional evidence you wish to have considered in your appeal must be
submitted with your request for hearing, by the date specified in your request for hearing, or if a hearing is scheduled, within 10
calendar days of receiving the notice of hearing from OMHA. If an expedited hearing is scheduled, even if you are not represented,
you must submit any additional evidence with your request for hearing, by the date specified in your request for hearing, or within 2
calendar days of receiving the notice of expedited hearing. If evidence is submitted later than the filing deadline, any applicable
adjudication period will be extended by the number of calendar days in the period between the filing deadline and the date when the
evidence is received.
If you are a Part D enrollee and you are submitting evidence of a change in condition that occurred after your original coverage
determination was made, the OMHA adjudicator will remand (return) your case to the Part D Independent Review Entity that issued
your reconsideration for a new decision.
If you are a provider, supplier, or beneficiary represented by a provider or supplier, and you are appealing a reconsideration issued
by a Medicare Part A or Part B Qualified Independent Contractor (QIC), any evidence that was not submitted prior to the QIC's
reconsideration must be accompanied by a statement explaining why the evidence was not previously submitted. The OMHA
adjudicator assigned to your appeal will consider this statement to determine whether you had good cause for submitting the
evidence for the first time at the OMHA level (for example, if the new evidence is material to an issue addressed in the QIC
reconsideration that was not identified as a material issue prior to the QIC's reconsideration). If you do not include a statement
explaining why the evidence was not previously submitted, or if the OMHA adjudicator determines you did not have good cause for
submitting the evidence for the first time at the OMHA level, the new evidence will not be considered. A good cause statement is not
required for evidence submitted by an unrepresented beneficiary, CMS or any of its contractors, a Medicaid State agency, an
applicable plan, or a beneficiary represented by someone other than a provider or supplier.
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)
Section 2: What is the information for the party filing new evidence? (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: What is the new evidence that you wish to submit? Please include the evidence with this form and describe the
evidence below, including the title, relevance, and date of creation. If you are required to do so, also include a good cause statement
explaining why this evidence was not previously submitted. If you need additional room, continue on a separate sheet of paper.
Section 5: Sign and date this form.
Party or Representative Signature Date
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-115 (03/17)
PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
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