Effective Dates: 02/04/2015 - Present
TN 5 (02-15)
A. Policy for requesting a hearing to dispute an income-related monthly adjustment amount
The Department of Health and Human Services’ (DHHS) Administrative Law Judges (ALJs) conduct all hearings in the Office of Medicare Hearings and Appeals (OMHA). The beneficiary (or legal guardian or parent of a minor) who wishes to appeal an income-related monthly adjustment amount (IRMAA) determination must complete the Form HA-501-U5 (Request for Hearing by Administrative Law Judge).
NOTE: Changes in IRS law grants SSA authorization to disclose information that we receive from IRS and that we use to make an IRMAA determination to OMHA ALJs and to the Medicare Appeals Council (MAC). There is no longer any form other than an HA-501-U5 needed for an appeal past the reconsideration level unless there is a representative involved with the appeal. If a beneficiary has a representative for an IRMAA appeal higher than the reconsideration level, DHHS requires an additional form:
DHHS requires Form CMS-1696 (Appointment of Representative) for all appeals when a representative payee is involved. If a beneficiary or representative contacts SSA to request Form CMS-1696, inform the caller they may request the form from the Medicare toll-free number (1-800-633-4227), (TTY or TDD 1-877-486-2048), or downloaded and printed from: CMS-1696.
B. How to handle a hearing request for service representative (SR) and 800 number agent (N8NN) or public contact employee
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If... |
then |
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you receive a completed HA-501-U5; |
give the completed form to a claims representative (CR). The CR inputs the information into the IRMAA Appeals Tracking System and sends it to the SEPSC at: Southeastern Program Service Center
P O Box 12247
Birmingham, AL 35202 |
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you receive a telephone request for a hearing; |
Inform the beneficiary that you are sending the necessary forms for completion. Inform the beneficiary that he or she must date and sign the HA-501-U5 in order to process the request. -
Mail the HA-501-U5 to the beneficiary.
Enclose a courtesy envelope addressed to:
Southeastern Program Service Center
P O Box 12247
Birmingham, AL 35202
If the beneficiary says he or she needs help completing the form, schedule an appointment with the servicing FO using the post-entitlement appointment calendar. |
C. Initiating the IRMAA hearing request process
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If... |
then |
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you receive a completed HA-501-U5; |
Access the IRMAA Appeals Tracking System:
Click on Establish/Update/Delete Appeal. Enter the Beneficiary’s own SSN (do not enter the claim number) and click the Search button. Click in the YES radio button to enter a new appeal, then click Continue. Enter your unit code, the beneficiary’s first name, middle initial and last name. Click Continue. Date of Determination – Enter the date of the determination being appealed. This date should be the date of the Reconsideration Notice. The date is always the notice date for the action being appealed. Date Appeal Filed – Enter the date the beneficiary requested the hearing. Select Event – Select the type of event the beneficiary is appealing. He or she can appeal the Initial Determination, LCE, More Recent Tax Information or Non-Qualifying Event. Date of the Event – Enter the date of the event being appealed. Beneficiary Report Date – Enter date the beneficiary reported the event being appealed – this date may be the same as the Date Appeal Filed if there was not a separate event reported that is being appealed. Reason For Appeal – Select the reason the beneficiary is filing the appeal. Select Level of Appeal - ALJ. Rep or Attorney – Select “Yes” if the beneficiary has a representative or attorney. Good Cause – The Good Cause button is grayed out for appeals above the Reconsideration level. -
Remarks – This field is a free format to add anything the beneficiary may have included on the paper HA-501-U5.
NOTE: The OMHA ALJ makes the determination of good cause based on the beneficiary’s statement entered in Remarks.
Click continue. Transfer hearing request to SEPSC for Action – If the appeal documentation is complete, the last screen is titled, “Transfer HHS appeal to SEPSC for Action.” Click the Transfer to SEPSC button. If it is necessary to pend the appeal for additional information, manually transfer the case to SEPSC by selecting the Transfer link from the IRMAA Main Menu/Action Page. Enter Destination Office Code- Enter C34. Enter Reason for Transfer – Add a message in this free format field. Click Transfer Case button. -
For additional assistance on how to complete the fields, see the Screen Help information located on each page.
Mail the completed forms to:
Southeastern Program Service Center
P O Box 12247
Birmingham, AL 35202
|
|
you receive a telephone request for a hearing; |
Inform the beneficiary that you are sending the necessary forms for completion. Inform the beneficiary that he or she must date and sign the HA-501-U5 in order to process the request. -
Mail the HA-501-U5 to the beneficiary.
Enclose a courtesy envelope addressed to:
Southeastern Program Service Center
P O Box 12247
Birmingham, AL 35202
If the beneficiary says he or she needs help completing the form, schedule an appointment with the servicing FO using the post-entitlement appointment calendar. |