DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR ESCALATION TO MEDICARE APPEALS COUNCIL
Instructions: This form may be used by the appellant in a Medicare Part A or Part B appeal of a Qualified Independent Contractor
(QIC) reconsideration that is pending at the Office of Medicare Hearings and Appeals (OMHA) to request escalation of the appeal to
the Medicare Appeals Council, provided that the appellant filed a timely request for hearing; the adjudication period, including any
extensions, has expired; and the appellant did not waive the adjudication period.
If your request meets these requirements, and OMHA is not able to issue a decision, dismissal, or remand within the later of five
calendar days of receiving this request for escalation, or five calendar days from the end of the applicable adjudication period, your
appeal will be escalated to the Medicare Appeals Council for review. Escalation is not available for a QIC dismissal of a request for
reconsideration.
To request escalation, 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: Escalation Request Mail Stop, 200 Public Square, Suite 1260, Cleveland, OH 44114-2316.
You must also send a copy of this request for escalation to the other parties who were sent a copy of the reconsideration decision in
your appeal.
Section 1: What is the appeal information?
OMHA Appeal Number (if known) Reconsideration Number (if OMHA appeal number not known)
Appellant Name
Assigned OMHA Adjudicator (if known)
Section 2: What is the requestor's Information
Name (First, Middle initial, Last) Firm or Organization (if applicable)
Mailing Address
City State ZIP Code
E-Mail Telephone Number Fax Number
Type of Requestor: Appellant
Representative
If you are a representative, have you filed an appointment of representative (CMS-1696) or other documents authorizing the
representation?
N/A
Yes
No (Please file the document(s) with this request.)
Section 3: Acknowledge the following by signing and dating below:
I certify that the request for hearing in the appeal identified in section 1 was timely filed; the applicable adjudication period,
including any extensions, has expired; and I have not waived the adjudication period.
•
I understand that if my appeal is escalated to the Medicare Appeals Council, OMHA will not issue a decision in this appeal and
the QIC reconsideration decision will be the decision that is subject to review by the Medicare Appeals Council.
•
I certify that I am sending a copy of this request for escalation to the parties who were sent a copy of the reconsideration decision.
•
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-384 (07/18)
PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
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