The amount in controversy must meet the threshold ($180 for 2024) to request an ALJ hearing

You can request an expedited hearing if your health is at immediate risk

Consider hiring a Medicare appeals attorney or advocate for ALJ hearings

Medicaremoderate

Part B Immunosuppressive Drug Coverage Enrollment

CMS-10798 · CMS

Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.

Form Details

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Where to Submit This Form

📬

Mail to your Medicare Advantage plan

Send to the address on your plan's reconsideration decision letter.

📠

Fax to your Medicare Advantage plan

Fax number on the reconsideration decision.

Filing Deadline

60 days from the date of the adverse reconsideration decision by the IRE.

Required Attachments

📎 Copy of the IRE reconsideration decision
📎 All prior appeal documentation
📎 Additional medical evidence or expert opinions
📎 Detailed written argument explaining why the denial is incorrect

Processing Time

90 days from the date OMHA receives the request. Expedited ALJ hearings may be available.

What Happens Next

The case will be assigned to an Administrative Law Judge at OMHA. You will receive a hearing notice with date and time. Hearings may be in person, by video, or by telephone.

Tips for This Form

✓ The amount in controversy must meet the threshold ($180 for 2024) to request an ALJ hearing
✓ You can request an expedited hearing if your health is at immediate risk
✓ Consider hiring a Medicare appeals attorney or advocate for ALJ hearings
✓ Submit all additional evidence at least 10 days before the hearing date

More Medicare Forms

Medicare Part B Enrollment

CMS-40B · CMS

Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.

Request for Employment Information

CMS-L564 · CMS

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.

Part A/B Special Enrollment (Exceptional Conditions)

CMS-10797 · CMS

Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.

Medicare Advantage Enrollment

Plan-specific (CMS model template) · CMS

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Medicare Advantage Disenrollment

CMS model disenrollment form · CMS

Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

Medicare Redetermination Request

CMS-20027 · CMS

First-level appeal for Original Medicare (Part A/B) claim denials. Must be filed within 120 days of the initial determination.

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