Medicare:  Hearing Request Reminders

     A request for hearing* must be filed within six months of the date of a review determination and at least $100 must be in controversy.  Claims can be combined to meet the $100 in controversy, but all claims must have had a review determination within six months of filing the review.

    There are different types of hearings available.  An On-The-Record (OTR) is the most common.  The decision is based on the facts in the file, and any additional information submitted with the hearing request.  Telephone hearings and in-person hearings are also available.  You should always specify which type of hearing you are requesting.

     If a telephone or in-person hearing is requested, the hearing officer may first prepare a decision based on the facts available.  In many cases, this process resolves the issue so that the more time-consuming process is not necessary.  Once the hearing officer renders the preliminary decision, the appellant has fourteen calendar days from the receipt of the decision to confirm whether the telephone or in-person hearing is still necessary or whether it is no longer needed.  If the appellant does not respond within 14 days, the preliminary decision becomes final and the appellant will lose the right to an in-person or telephone hearing.  (If the amount of controversy is $500 or more, the appellant still has the right to request an Administrative Law Judge (ALJ) hearing within 60 days of the hearing decision.)  If the appellant responds after the 14 calendar days, good and sufficient cause must be shown for not responding timely.  The hearing officer will consider whether good cause has been demonstrated.  If good cause is established, a new hearing officer will be assigned the case to complete the telephone or in-person that was originally requested.

 * To qualify for a hearing, a review must first have been completed.  However, a review is not a prerequisite in these two exceptions:  payment of claims not acted upon with reasonable promptness by the carrier and appeals of revised initial determinations where $100 or more remains in controversy.

Further information on hearing requests and forms may be found at www.cms.gov/professionals - (please note - some forms are not available on-line)