ALJ Hearing
Administrative Law Judge Hearing
The third level of the Medicare claims appeal process, before an Administrative Law Judge at OMHA.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Denials & Appeals
- Acronym for
- Administrative Law Judge Hearing
- Primary sources
- 1
- Workspace handoff
- denial workbench →
Where this comes up
This is denial-workbench territory. A remit posts with a CARC/RARC, the biller decides whether to rebill, appeal, or write off, and the appeal packet has to cite the chart, the order, and the payer's own policy language. Recurring patterns trace back to an upstream workflow gap.
Full definition
What it is in practice
The Office of Medicare Hearings and Appeals (OMHA) holds ALJ hearings. The request must be filed within 60 days of the Reconsideration decision; the amount-in-controversy threshold for 2024 is $180+. Hearings have historically had multi-year backlogs.
How it shows up in your practice
Group small denials into a single ALJ filing to clear the AIC threshold. Build the clinical narrative carefully — ALJs reverse a meaningful share of well-documented appeals.
Sources
- CMS — Medicare Claims Appeals Processhttps://www.cms.gov/medicare/appeals-grievances/fee-for-service/original-medicare-ffs-appeals
Prepare ALJ filings in the Denial Workbench
Open denial workbench →Related terms
- Denials & AppealsMedicare Appeals LevelsThe five-level Medicare appeals process: Redetermination, Reconsideration, ALJ Hearing, Medicare Appeals Council, and Federal District Court.
- Denials & AppealsReconsiderationThe second level of the Medicare claims appeal process, conducted by a Qualified Independent Contractor (QIC).
- Denials & AppealsMedicare Appeals CouncilThe fourth level of the Medicare claims appeal process, conducted by the Departmental Appeals Board.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedicare Appeals CouncilThe fourth level of the Medicare claims appeal process, conducted by the Departmental Appeals Board.
- GlossaryMedicare Appeals LevelsThe five-level Medicare appeals process: Redetermination, Reconsideration, ALJ Hearing, Medicare Appeals Council, and Federal District Court.
- GlossaryReconsiderationThe second level of the Medicare claims appeal process, conducted by a Qualified Independent Contractor (QIC).
- GlossaryAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- GlossaryAudit DefenseThe organized process of preparing for and responding to a payer or government audit.
- GlossaryRedeterminationThe first level of the Medicare claims appeal process, conducted by the MAC.
- BillingHow to Appeal an Insurance Denial: Step-by-Step GuideClaim denied? Step-by-step appeal process with payer deadlines, denial code fixes, appeal letter template, and escalation options.
- BillingMedical Billing Denial Codes: What They Mean and How to Fix ThemCO-4, CO-97, CO-16, PR-96 and more. What each denial code means and exactly how to fix it.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.