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                              Forms Needed for Your Level 3 Appeal
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Forms Needed for Your Level 3 Appeal








  
  
    

  
      



Below is a list of **Level 3 forms only** that may pertain to your request for a hearing by an Administrative Law Judge.

Request or Waive an Administrative Law Judge Hearing with OMHA
	Pre-Hearing Forms Needed by OMHA
	Records, Record Change, and Information Requests
	Request for Substitution Upon Death of Beneficiary
	Petition to Obtain Approval of a Fee for Representing a Beneficiary
	Request to Escalate Your Appeal
	After your AppealRequest or Waive an Administrative Law Judge Hearing with OMHA

Form
			Description**Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal**Form OMHA-100Form OMHA-100 (Large Print)Form OMHA-100 - (in Spanish)Form OMHA-100 (Large Print) - (in Spanish)
			This form is used to request review of a reconsideration determination or dismissal issued by a Qualified Independent Contractor (QIC) or Independent Review Entity (IRE). Remember, the remaining amount in controversy must meet the current minimum for an ALJ review.
			For appeals related to Medicare Part A or Part B, you may file your appeal request online. Visit the OMHA e-Appeal Portal (Portal) and register for an account. Through the Portal, you may directly upload Form OMHA-100 or use the guided tutorial to create and upload your request.
			To appeal by mail, send your request to:
			OMHA Central Operations
			1001 Lakeside Ave., Suite 930
			Cleveland, OH 44114-1158
			Note: If you are a beneficiary or represent a beneficiary, mail your request to:  
			OMHA Central Operations
			Attn: Beneficiary Mail Stop
			1001 Lakeside Ave., Suite 930
			Cleveland, OH 44114-1158 
			Whether you file online or by mail, you must also send a copy of the appeal request to the other parties who received a copy of the reconsideration that you are appealing (hint: look at the CC (or copy) section of the notice).**Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal – Multiple Claim Attachment**Form OMHA-100AForm OMHA-100A - (in Spanish)Form OMHA-100A (Large Print) - (in Spanish)
			This form is used as an attachment to form OMHA‐100 to identify multiple beneficiaries or enrollees associated with a single request for an Administrative Law Judge (ALJ) hearing or a review of dismissal.**Request for Extension of Time to File a Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal**Form OMHA-103Form OMHA-103 - (in Spanish)Form OMHA-103 (Large Print) - (in Spanish)
			This form is used to request an extension to submit your request for an Administrative Law Judge (ALJ) hearing or review of a dismissal with the Office of Medicare Hearings and Appeals (OMHA) beyond the normal 60 calendar days following receipt of a reconsideration or dismissal. An ALJ or attorney adjudicator has the discretion to accept your request based on your good cause explanation as to why you are unable to submit your request for hearing or review of a dismissal within the 60 days, or to determine that you did not have good cause for late filing of a request for review of a dismissal. However, only an ALJ may determine that you did not have good cause for late filing of a request for hearing.**Waiver of Advance Written Notice of Hearing**Form OMHA-143Form OMHA-143 (Large Print)
			This form may be used by parties and participants to waive the requirement that written notice of an Administrative Law Judge hearing be mailed, transmitted, or served at least 20 calendar days before the date of the hearing, or at least 3 calendar days before the date of an expedited Part D hearing.**Withdrawal of Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal**Form OMHA-119Form OMHA-119 - (in Spanish)Form OMHA-119 (Large Print) - (in Spanish)
			This form is used to withdraw your request for an Administrative Law Judge (ALJ) hearing or review of a dismissal before the Office of Medicare Hearings and Appeals (OMHA). If you file this form, your appeal will be dismissed by the OMHA adjudicator if no other party has filed a valid request for an ALJ hearing or review of a dismissal. Your request will not be honored if the ALJ has already issued a decision or other dispositive order.**Waiver of Right to an Administrative Law Judge (ALJ) Hearing**Form OMHA-104Form OMHA-104 - (in Spanish)Form OMHA-104 (Large Print) - (in Spanish)
			This form is used to waive your right to have an oral hearing before the Administrative Law Judge (ALJ). If you and all of the other parties who would receive a notice of hearing waive this right, your case will be decided on the record without an oral hearing.**Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ) Hearing**Form OMHA-114Form OMHA-114 - (in Spanish)Form OMHA-114 (Large Print) - (in Spanish)
			This form is used to withdraw your prior decision to waive your right to have a hearing before the Administrative Law Judge (ALJ). Your request may be honored only if the ALJ has not yet issued a decision. The ALJ may extend the decision-making time frame beyond the normal period in order to schedule and hold the hearing.Pre-Hearing Forms Needed by OMHA

Form
			Description**Response to Notice of Hearing**Form OMHA-102Form OMHA-102 - (in Spanish)Form OMHA-102 (Large Print) - (in Spanish)
			This form is used to indicate whether you intend to be present at the time and place of a scheduled hearing. You need to complete sections 2 through 8 and return the form to the assigned Administrative Law Judge (ALJ) within 5 calendar days of receipt (2 calendar days for expedited Part D hearings).**Identity Verification**Form HHS-733
			This form is used by the Office of Medicare Hearings and Appeals when it needs to confirm your identity.**Filing of New Evidence**Form OMHA-115Form OMHA-115 - (in Spanish)Form OMHA-115 - (Large Print) - (in Spanish)
			This form is used to submit additional evidence to be considered by the assigned OMHA adjudicator.**Appointment of Representative**Form CMS-1696
			This form is used to appoint a representative to assist with an appeal.  An appointed representative may be a family member, friend, lawyer or provider/supplier.**Notice of Intent to Participate in Proceedings on a Request for an Administrative Law Judge (ALJ) Hearing or to be a Party to an ALJ Hearing**Form OMHA-105
			This form is for CMS, a CMS contractor, or a Part D Plan Sponsor that wishes to elect (in Medicare Part A and B appeals) or request (in Medicare Part D appeals) to be a participant in the proceedings on a request for an Administrative Law Judge (ALJ) hearing. CMS or a CMS contractor may alternatively use this form to elect to be a party to an ALJ hearing in a Medicare Part A or Part B appeal, if one is scheduled and the request for hearing was not filed by an unrepresented beneficiary.Records, Record Change, and Information Requests

Form
			Description**Request for Copy of the Record(s) in the Case File**Form HHS-719
			This form is used by you or your authorized or appointed representative to request a copy of all or part of your record.**Request for Copy of the Record(s): Third-Party with the Individual Appellant's Consent**Form HHS-720
			This form is used by a third party to request, with your consent, a copy of all or part of your record.**Individual Appellant's Consent to Third-Party for Copies of the Individual Appellant's Record(s)**Form HHS-721
			This form is used by you to consent to a request by a third party to receive a copy of all or part of your record.**Request to Correct, Amend, or Delete a Record(s)**Form HHS-724
			This form is used to request a correction, amendment, or deletion of a record. After you submit this form, it is up to the Administrative Law Judge (ALJ) to determine whether the record should be corrected, amended, or deleted.**Payment Information Report**Form HHS-734
			This form is used by the Office of Medicare Hearings and Appeals to collect your bank information in order to make the direct deposit into your account. This is not payment of Medicare services.Request for Substitution Upon Death of Beneficiary

Form
			Description**Request for Substitution of Party Upon Death of Beneficiary or Enrollee**Form OMHA-106
			This form allows a substitute party to enter the proceedings if the Medicare beneficiary or enrollee died after a hearing was requested but before a decision, dismissal, or remand was issued. The substitute party can be either someone with legal authority to act on behalf of the beneficiary or enrollee or, if no such individual exists with a genuine financial interest, it can be the provider or supplier who furnished items or services.Representative Fees

Form
			Description**Petition to Obtain Approval of a Fee for Representing a Beneficiary**Form OMHA-118
			This form is used by an attorney or other appointed representative for a beneficiary to request approval to charge a fee for services rendered in connection with an appeal before OMHA.Request to Escalate Your Appeal

Form
			Description**Request for Escalation to Medicare Appeals Council**Form OMHA-384Form OMHA-384 (Large Print)
			If your Medicare Part A or Part B appeal of a Qualified Independent Contractor (QIC) reconsideration is pending at OMHA and the adjudication period has elapsed, this form may be used to request escalation of your appeal to the Medicare Appeals Council. Escalation is not available for a QIC dismissal of a request for reconsideration, or if your request for hearing was not timely filed.After Your Appeal

Form
			Description**Request for Review of a Remand**Form OMHA-107Form OMHA-107 - (in Spanish)Form OMHA-107 (Large Print) - (in Spanish)
			If you are a party to an appeal, CMS, a CMS contractor, or a Part D plan sponsor, and you have received notice of a remand from OMHA that you believe was not authorized by the governing regulations, you may use this form to request that the OMHA Chief Administrative Law Judge, or designee, review the remand.

                    
  


Content created by Office of Medicare Hearings and Appeals (OMHA) Content last reviewed December 19, 2023 Back to top
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