Office of Medicare Hearings and Appeals (OMHA)

About OMHA

The Office of Medicare Hearings and Appeals (OMHA) is responsible for Level 3 of the Medicare claims appeal process and certain Medicare entitlement appeals and Part B premium appeals.

OMHA was created by the Medicare Modernization Act of 2003 to simplify the appeals process and make it more efficient. During an appeal, an OMHA Administrative Law Judge conducts a new ("de novo") review of an appellant's case and issues a decision based on the facts and the law.

The Chief Administrative Law Judge leads the entire agency, which consists of four field offices and a headquarters office. Each field office includes many Administrative Law Judges who are overseen by an Associate Chief Administrative Law Judge. Appeals are assigned to these Administrative Law Judges by a Centralized Docketing Division in accordance with standardized procedures.

Contact information for each OMHA field office is available.

Legislation

The Legislation section includes background information on the laws that govern OMHA, your privacy rights, and Medicare.

The Medicare Modernization Act of 2003. The Medicare Modernization Act of 2003 set forth a number of major changes to the Medicare program, including (1) the creation of OMHA, (2) the creation of the new Medicare Part D drug benefit starting in 2006, (3) the creation of Health Savings Accounts (HSAs) and (4) increased payments to Medicare HMOs under the renamed Medicare Advantage program.

Benefits Improvement Protection Act (BIPA) Section 521 [ PDF - 52KB]. Section 521 of the Medicare, Medicaid, and Supplemental Children Health Insurance Plan (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA), amended section 1869 of the Social Security Act (the Act) to require significant changes to the Medicare appeals procedures. Among these changes is a new requirement for a process by which a beneficiary may obtain an expedited determination in response to the termination of provider services.

Medicare Part C Regulation. Medicare Advantage Plans (also known as Medicare Part C Plans) are managed health plan options that are part of the Medicare program. These plans were once called “Medicare+Choice Plans”. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include Medicare Part D prescription drug coverage or you can enroll in a separate Medicare Part D prescription drug coverage plan (See information on Medicare Part D below). Medicare Advantage Plans include:

Medicare Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPO)
Private Fee-for-Service (PFFS) Plans
Medicare Special Needs Plans

Medicare Part D Regulation. The recent legislation provides Medicare-eligible seniors and people with disabilities with the first prescription drug benefit offered under the Medicare program.