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Original Medicare: Claims: Appeals

Appeal #3

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If the second appeal is denied, and the amount in dispute in 2013 and 2014 is at least $140, you have 60 days to appeal again.

This time the appeal is to an Admnistrative Law Judge (ALJ) of the U.S. Department of Health and Human Services. The denial letter includes filing instructions.

Hearings by an ALJ are like going to court except the proceeds are generally informal. The idea is for the judge to impartially review the evidence to determine whether your requested health care should be covered by Medicare. Unlike the hearings you see on T.V., a hearing in front of an ALJ does not pit you against Medicare.

Because ALJs are only in limited locations, ALJ hearings are usually conducted by telephone. They can also be by videoconference if you have, or have access to, the required technology. (If the hearing is by video conference, let the ALJ see your real physical condition. Don't try to hide it or play it down.)

When the hearing starts, be sure the judge has a copy of all of the evidence you previously submitted. It is best to ask about each specific document rather than a general question such as "Do you have all the evidence I previously submitted?"

Explain your situation and why you require the care in dispute. Keep in mind that the judge is human: it can't hurt to let the judge know if you have limited financial means and can't afford the requested care on your own.

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