Medical Billing: How to Request a Hearing with an Administrative Law Judge (ALJ)

By Karen Smiley from Medical Billing and Coding For Dummies

In medical billing, you may find yourself faced with a difficult Medicare situation and need an ALJ hearing. If you have tried a request for redetermination and a QIC reconsideration and are still unsatisfied, you may request an Administrative Law Judge hearing. You can find the necessary form (everything requires a form!) at the Medicare website.

You can also present your case in writing. In this request, outline the area in dispute, along with the case number assigned by the QIC, the Medicare number of the patient, the original claim number assigned by the Medicare contract, and all evidence previously submitted. You must also identify the claims processing rules that support your request and the reason you feel the process has not been followed.

Currently the amount in dispute must be a minimum of $130 before an ALJ hearing can be requested. This amount may increase annually based on the consumer price index.

When conducting a claims review, the judge conducts a hearing, reviews all the evidence, and makes a decision based upon Medicare rules and the law. Most hearings are held via videoconference or telephone, although you may request a hearing in person. The judge decides whether a hearing of this type is warranted.

You may also request that the judge make a decision without a hearing, based solely upon the written evidence submitted. Medicare and its contractors are also notified of the hearing and are allowed to participate.

Hearings are conducted in person and over the phone. You may also request that the ALJ review the evidence and make a ruling. In a hearing, both parties are entitled to attend, although Medicare usually declines. The burden of proof is on the provider. For this reason, some providers rely on legal representation if the amount in question is large. The ALJ level of appeal is not for the novice.

The ALJ normally makes a decision within 90 days, although this time frame is often extended for several reasons, including a heavier than normal caseload and evidence being submitted late.

If your claim is denied by the ALJ and you still feel that your claim has been processed incorrectly, the next level of appeal is the Medicare Appeals Council.

The Office of Medicare Hearings and Appeals was created by the Medicare Modernization Act of 2003. This office is there to streamline the process and make it more efficient. The people in this office include a Chief Administrative Law Judge and the regional or Associate Chief Administrative Law Judges, each of whom has an assistant known as the Hearing Office Director. OMHA is responsible for the level-three Medicare appeals process.