Printable blank Form OMHA-100

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What is Form OMHA-100?

Form OMHA-100 is a request for administrative law judge hearing or review of dismissal. It may be used by the Medicare beneficiaries or enrollees, the providers or suppliers that furnish services or items to the Medicare beneficiaries or by Medicare State agencies.

What I need the Form OMHA-100 for?

  • To request review of a reconsideration determination or dismissal issued by a qualified independent contractor or an independent review entity;
  • The form is suitable for four Medicare Parts and for beneficiaries or enrollees, providers and suppliers, Medicaid State agencies or an applicable plan appealing a Medicare Secondary Payer issue.

How to fill out Form OMHA-100?

The form consists of two pages and ten fillable sections in total. To correctly fill Form OMHA-100, you will need to:

  • deliver the information about yourself or the party you represent;
  • state what is being appealed;
  • explain why you disagree with the Reconsideration or Dismissal being appealed;
  • give additional information about your appeal;
  • certify the copies sent to other parties.

A fillable Form OMHA-100 is available above, but it is also important to send it correctly. For issues related to different Medicare parts there are different mail stops. The full list with the instructions on mailing is available on the official website of the U.S. Department of Health and Human Services.

Organizations that work with Form OMHA-100

Office of Medicare Hearings and Appeals (OMHA)

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