A medicare administrative law judge hearing is where most families finally get a live human being to listen. You have probably been through two rounds of paper already. A claim was denied. You appealed, and a contractor said no. You appealed again, and a second contractor said no. Now you are holding a reconsideration notice with a paragraph at the bottom about Level 3. That paragraph is the door to a medicare administrative law judge hearing, and it comes with a hard 60-day clock.
- What “medicare administrative law judge hearing” Actually Means
- The Deadline You Cannot Miss
- How to Start a Medicare Administrative Law Judge Hearing
- What to Put in the File
- If the First Level Says No
- Mistakes That Sink a Medicare Administrative Law Judge Hearing
- Frequently Asked Questions
- Key Takeaways: Medicare Administrative Law Judge Hearing
- Where to Get Free Help
- Official Sources & Resources
- Related Guides
This guide walks through what that level actually looks like, what to file, and who to call for free help.
What “medicare administrative law judge hearing” Actually Means
Medicare appeals run in five levels. A medicare administrative law judge hearing is Level 3. It is decided by an administrative law judge or an attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA), a separate HHS agency.
OMHA does not work for CMS. It does not work for your Medicare Advantage plan. That independence is the point of the level.
Unlike Levels 1 and 2, this is not a paper-only review. You can speak. Hearings are usually held by telephone or video, not in a courtroom. Your doctor can appear. So can a family member you have appointed in writing.
The judge looks at the record again from scratch. Per CMS guidance on the third level of appeal, this is a new review, not a rubber stamp of the contractor below. Nothing here guarantees a result.
The Deadline You Cannot Miss
You have 60 calendar days to request a medicare administrative law judge hearing. The clock starts on the date you received the Level 2 decision.
In Original Medicare, that notice is the Medicare Reconsideration Notice from the Qualified Independent Contractor (QIC). In a Medicare Advantage or Part D case, it is the reconsideration decision from the Independent Review Entity (IRE). As of May 1, 2026, C2C Innovative Solutions is the Part C IRE; requests received on or before April 30, 2026 stayed with Maximus.
Receipt is presumed to be 5 days after the date printed on the notice unless you can show otherwise. So count from that presumed date, not from the day you opened the envelope.
There is also a dollar floor. For calendar year 2026 the amount in controversy is $200 for a medicare administrative law judge hearing, and $1,960 to reach federal court at Level 5. Confirm the current figure on the CMS page above before you rely on it, since it is reset each year by Federal Register notice.
| Level | Notice that starts the clock | Who decides | Form | Deadline to file |
|---|---|---|---|---|
| 1 — Redetermination | Medicare Summary Notice (MSN) or plan denial | Medicare Administrative Contractor (or your plan) | CMS-20027 | 120 days from receipt (Original Medicare) |
| 2 — Reconsideration | Medicare Redetermination Notice (MRN) | Qualified Independent Contractor (QIC) or IRE | CMS-20033 | 180 days from receipt (Original Medicare) |
| 3 — Hearing | Medicare Reconsideration Notice / IRE decision | ALJ or attorney adjudicator at OMHA | OMHA-100 | 60 days from receipt |
| 4 — Council review | ALJ decision or dismissal | Medicare Appeals Council (DAB) | DAB-101 | 60 days from receipt |
| 5 — Judicial review | Council decision | Federal district court | Court complaint | 60 days from receipt |
Deadlines differ by plan type. Verify yours against the exact notice in your hand and the Medicare.gov appeals pages.
How to Start a Medicare Administrative Law Judge Hearing
Step one: find the appeal rights section on your reconsideration notice. It names the OMHA office and the mailing address for your case.
Step two: complete Form OMHA-100, Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal. It is free at the OMHA forms page. A letter with the same information also works, but the form prevents omissions.
Step three: include the beneficiary name, Medicare number, the appeal number from the Level 2 notice, the dates of service, and the items in dispute.
Step four: mail it where the notice tells you. Most beneficiary requests go to OMHA Central Operations, 1001 Lakeside Ave., Suite 930, Cleveland, OH 44114-1158. Write “Attn: Beneficiary Mail Stop” on the envelope. You may also be able to file electronically through the OMHA portal.
Step five: send a copy to the other parties listed on the notice. Keep proof of mailing.
If you are already past 60 days, do not give up on a medicare administrative law judge hearing. File anyway and attach Form OMHA-103, the request for extension of time, explaining the good cause for the delay. The adjudicator decides whether to accept it.
OMHA generally aims to decide within 90 calendar days. Expedited Part D appeals are handled in about 10 days. Backlogs have shortened, but timing varies.
What to Put in the File
The judge reads what you send. Assume nothing arrives on its own.
Include the denial notices from Levels 1 and 2, the itemized bill or claim, the relevant medical records, and the plan’s coverage rules if it is a Part C or Part D case. Add the appointment of representative form (CMS-1696) if someone is speaking for the beneficiary.
The single most useful document is a letter from the treating physician. Not a form. A letter.
Ask the doctor to state the diagnosis, what was ordered, why it was medically necessary for this person, and which Medicare coverage criterion or plan policy is met. Ask them to name the specific policy language. Vague support letters rarely move anything.
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New evidence at Level 3 may need Form OMHA-115 and, for some appellants, a statement explaining why it was not filed earlier.
If the First Level Says No
If the ALJ or attorney adjudicator rules against you, Level 4 is the Medicare Appeals Council at the Departmental Appeals Board. You have 60 calendar days from receipt of the decision. The Council suggests Form DAB-101.
If OMHA blows the 90-day window, you may be able to escalate to the Council instead of waiting. The decision notice or OMHA staff can confirm whether escalation applies to your case.
Free help exists at every level. Call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day. Call your State Health Insurance Assistance Program at 1-877-839-2675 or find it at shiphelp.org. SHIP counseling is free and unbiased.
For hospital discharge and skilled nursing termination appeals, call the Beneficiary and Family Centered Care QIO printed on your Important Message from Medicare or Notice of Medicare Non-Coverage. The Medicare Rights Center runs a free helpline at 1-800-333-4114. The Center for Medicare Advocacy publishes free self-help packets.
Mistakes That Sink a Medicare Administrative Law Judge Hearing
Counting from the wrong day. The 60 days run from receipt of the Level 2 notice, presumed 5 days after its date. People count from the hearing request instead and lose weeks.
Skipping levels. You cannot jump straight to a medicare administrative law judge hearing without a completed Level 2 reconsideration.
Sending the request to the plan or the QIC instead of OMHA. Only the address on the notice is correct.
Filing without an appointment of representative. A spouse or adult child cannot argue the case at a medicare administrative law judge hearing without CMS-1696 or an equivalent written appointment on file.
Declining the hearing. Waiving it means the record speaks alone. Live testimony from the treating clinician is often the only chance to explain the patient behind the paperwork.
Frequently Asked Questions
Do I need a lawyer for a medicare administrative law judge hearing?
No. Beneficiaries represent themselves at OMHA every day, and a family member can be appointed instead. SHIP counselors and the Medicare Rights Center helpline are free. This article describes process only and is not legal advice.
Where does the hearing happen?
Usually by telephone or video conference. OMHA sends a Notice of Hearing with the date, time, and dial-in details. Form OMHA-102 is used to respond to that notice.
What if my claim is worth less than $200?
Small claims can sometimes be combined to meet the 2026 amount in controversy. Ask OMHA at 1-855-556-8475 whether aggregation applies before you assume you are shut out.
Does Medicare Advantage use the same Level 3?
Yes. Part C and Part D appeals reach the same OMHA judges after the IRE stage, on the same 60-day clock. Confirm your plan’s earlier deadlines on the Medicare health plan appeals page, since the Level 1 window is set by the plan notice.
Key Takeaways: Medicare Administrative Law Judge Hearing
- The clock starts with the notice. Every medicare administrative law judge hearing deadline runs from the date on the letter, not the day you read it.
- Appeals are free. Filing a medicare administrative law judge hearing costs nothing, and asking does not affect your other Medicare coverage.
Where to Get Free Help
Three doors cost nothing. Your State Health Insurance Assistance Program (SHIP) counselor will work the medicare administrative law judge hearing with you; find yours through medicare.gov. The Medicare Rights Center helpline answers appeal questions nationally. And 1-800-MEDICARE can tell you exactly which notice you are holding.
Official Sources & Resources
- Medicare appeals overview: https://www.medicare.gov/claims-appeals
- Center for Medicare Advocacy: https://medicareadvocacy.org
- Medicare Rights Center: https://www.medicarerights.org
- Medicare.gov: https://www.medicare.gov
- CMS.gov: https://www.cms.gov
- Find your SHIP counselor: https://www.medicare.gov/talk-to-someone
Checked against the official sources above in September 2026. Rules and dollar figures change; if a notice you received disagrees with this page, the notice wins — and please tell us. General information, not legal, financial or medical advice.