CMS Pub. 100-04, ch. 29, § 330

Review at the Office of Medicare Hearings and Appeals (OMHA) - The Third

Level of Appeal

(Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19)

A party to a QIC reconsideration may request a hearing before an ALJ if the party files a written

request for an ALJ hearing within 60 days after receipt of the notice of the QIC’s

reconsideration and the amount in controversy requirement is met*. A party who files a timely

appeal before a QIC and whose appeal continues to be pending before a QIC at the end of the

QIC’s decision-making timeframe has a right to a hearing before an ALJ if the party files a

written request with the QIC to escalate the appeal to the ALJ level after the adjudication period

expires and the QIC does not issue a final action within 5 days of receiving the request for

escalation. A party wishing to escalate an appeal must also meet the amount in controversy

requirement*. A party to a QIC’s dismissal of a request for reconsideration has a right to have

the dismissal reviewed by an ALJ or attorney adjudicator if the party meets the amount in

controversy requirement*.

*See §250 for AIC information. The current amount in controversy requirements can be found

on the CMS.gov claims appeals webpage: http://www.cms.gov/Medicare/Appeals-and-

Grievances/OrgMedFFSAppeals/Downloads/AppealsProcessFlowchart-FFS.pdf