(a) If a party is dissatisfied with a QIC's reconsideration, or if the adjudication period specified in § 405.970 for the QIC to complete its reconsideration has elapsed, the party may request a hearing before an ALJ.
(b) A hearing before an ALJ may be conducted in-person, by video-teleconference (VTC), or by telephone. At the hearing, the parties may submit evidence (subject to the restrictions in § 405.1018 and § 405.1028), examine the evidence used in making the determination under review, and present and/or question witnesses.
(c) In some circumstances, CMS or its contractor may participate in the proceedings under § 405.1010, or join the hearing before an ALJ as a party under § 405.1012.
(d) The ALJ or attorney adjudicator conducts a de novo review and issues a decision based on the administrative record, including, for an ALJ, any hearing record.
(e) If all parties who are due a notice of hearing in accordance with § 405.1020(c) waive their right to appear at the hearing in person or by telephone or video-teleconference, the ALJ or an attorney adjudicator may make a decision based on the evidence that is in the file and any new evidence that is submitted for consideration.
(f) The ALJ may require the parties to participate in a hearing if it is necessary to decide the case. If the ALJ determines that it is necessary to obtain testimony from a non-party, he or she may hold a hearing to obtain that testimony, even if all of the parties who are entitled to a notice of hearing in accordance with § 405.1020(c) have waived the right to appear. In that event, however, the ALJ will give the parties the opportunity to appear when the testimony is given, but may hold the hearing even if none of the parties decide to appear.
(g) An ALJ or attorney adjudicator may also issue a decision on the record on his or her own initiative if the evidence in the administrative record supports a fully favorable finding for the appellant, and no other party to the appeal is liable for the claims at issue, unless CMS or a contractor has elected to be a party to the hearing in accordance with § 405.1012.
(h) If more than one party timely files a request for hearing on the same claim before a decision is made on the first timely filed request, the requests are consolidated into one proceeding and record, and one decision, dismissal, or remand is issued.
[82 FR 5109, Jan. 17, 2017]
Notes of Decisions
Cited in
34
cases (
16 in the last 5 years), 2009–2025 · leading case:
Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018).
Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018).
“§ 1395ff(d) ; 42 C.F.R. § 405.1000 (d). The ALJ stage presents the opportunity to have a live hearing, present testimony, cross-examine witnesses, and submit written statements of law and fact.”
Med-Cert Home Care, LLC v. Azar, 365 F. Supp. 3d 742 (N.D. Tex. 2019).
· cites it 2× “§ 1395ff(d) ; 42 C.F.R. § 405.1000 (d). The ALJ stage presents the opportunity to have a live hearing, present testimony, cross-examine witnesses, and submit written statements of law and fact.”
Cumberland Cnty. Hosp. Sys., Inc. v. Burwell, 816 F.3d 48 (4th Cir. 2016).
“§ 1395ff(d)(l); 42 C.F.R. § 405.1000 . The ALJ hearing process is administered by OMHA, a division within HHS that is independent of and funded through an appropriation separate from the division that oversees the contractors’ review during the first two steps of the…”
Arturo Porzecanski v. Alex Azar, 943 F.3d 472 (D.C. Cir. 2019).
“See 42 C.F.R. § 405.1000 . The ALJ’s decision is binding on the parties unless reviewed by the Medicare Appeals Council (Council).”
Gurpreet Padda v. Xavier Becerra, 37 F.4th 1376 (8th Cir. 2022).
“42 C.F.R. § 405.1000 (b). The ALJ must issue a decision within 90 days of the request for hearing.”
Infinity Healthcare Servs., Inc. v. Azar, 349 F. Supp. 3d 587 (S.D. Tex. 2018).
“§ 1395ff(d) ; 42 C.F.R. § 405.1000 (d). The ALJ stage presents the opportunity to have a live hearing, present testimony, cross-examine witnesses, and submit written statements of law and fact.”
North Carolina Ins. Guar. Ass'n v. Xavier Becerra, 55 F.4th 428 (4th Cir. 2022).
“42 C.F.R. § 405.1000 . Fourth, if the insurer is not satisfied with the ALJ’s decision, it can request that the Medicare Appeals Council (the “Council”) review that decision.”
Willowood of Great Barrington, Inc. v. Sebelius, 638 F. Supp. 2d 98 (D. Mass. 2009).
“§ 1395ff(d)(l)(A); 42 C.F.R. §§ 405.1000 , 405.1002. At the hearing, the claimant has an opportunity to submit new evidence, and, if the contractor elects to participate in the hearing, the claimant may take discovery.”
B & H Med., LLC v. United States, 116 Fed. Cl. 671 (Fed. Cl. 2014).
“Hearing before an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals ( 42 C.F.R. §§ 405.1000 -.1054); 4. Review by the Medicare Appeals Council ( 42 C.”
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