(and did you know that EAJR was even a thing?)
Most practitioners are familiar with the basics of the appeals process when audited by the Centers for Medicare & Medicaid Services (CMS) over Medicare Part A and Part B claims. I think by now, everyone is familiar with the fact that first there is a Redetermination by the Medicare Administrative Contractor (MAC), after which there is a Reconsideration by a Qualified Independent Contractor, then a decision by the Office of Medicare Hearings and Appeals, and perhaps a hearing in front of an Administrative Law Judge (ALJ). I simplified this a bit because there could be a review by the Medicare Appeals Council in there somewhere. For physicians to challenge denied payments in an appeal to the ALJ, the amount in controversy must now meet a higher minimum threshold compared to previous years. In 2022, the minimum threshold for an ALJ hearing was ~$170, and in 2025, it increased to $190. In 2026, the ALJ threshold has risen to $200.
Physicians who don’t want to attend an ALJ hearing have the option of filing a waiver of right to an ALJ hearing (Form OMHA-104). However, an ALJ may determine it’s necessary to hold a hearing even if all parties involved have waived their rights to a hearing.
Additionally, if the ALJ renders an unfavorable decision, the physician can appeal that decision to the Medicare Appeals Council. If the Council renders a decision that the physician finds unfavorable, the physician can file an action in federal district court within 60 days of that decision.
“If the ALJ’s decision is unfavorable, the decision will contain information needed to file a request for review by the Medicare Appeals Council,” CMS added in its online guidance. Forms for the appeals are available through the U.S. Department of Health and Human Services website. For Medicare Advantage, CMS notes that an initial appeal determination is made by the insurance company issuing the plan, which also handles what CMS terms the Level 1 Appeal. Beyond that, a physician can appeal to Maximus, a Part C Independent Review Entity (IRE), and physicians can appeal an IRE’s adverse decision by requesting an ALJ hearing.
In addition to the ALJ, there’s another process called an Expedited Access to Judicial Review (EAJR), which I had never heard of before. If a dispute is eligible for EAJR, the physician would submit a request for that review after the second level of appeal. I only just read about the EAJR when CMS announced that the EAJR judicial review monetary threshold has increased. In 2022 it was $1,670, and in 2025, it was $1,850. In 2026, the EAJR threshold has risen to $1,960. Personally, I would need to have a lot more than $1,960 in question to make it worth hiring the help needed to go through this process with CMS. However, I had never heard of the EAJR at all, much less the fact that there’s a monetary threshold.
I hope those of you who are experts at the appeals process will provide some information in a guest blog about the EAJR process.
