The ALJ hearing represents which level in the Medicare appeal process?

• A. First level
• B. Second level
• C. Third level
• D. Fourth level

Answer: (C)

The ALJ hearing sits at the third step in the Medicare appeal sequence. After an initial determination is issued by a Medicare contractor, a reconsideration is allowed by a different reviewer (the QIC). If still unresolved, the next formal stage is a hearing before an Administrative Law Judge, where you can present new evidence and witness testimony, and the ALJ issues a decision. If further review is needed, the next level is review by the Medicare Appeals Council, and finally, the option to go to federal district court. Because the ALJ hearing occurs after the initial determination and the reconsideration, it is the third level.