Medicare Enrollment Appeals Beyond Reconsideration

Most Medicare enrollment disputes should be won or lost at reconsideration, because that is where the record is built. When a reconsidered determination goes against you, though, the regulations in 42 CFR Part 498 give you three more levels: an administrative law judge (ALJ), the Departmental Appeals Board (DAB), and federal district court. Each is more formal than the last, and each is a place where a healthcare attorney should be leading.

The rules below come from the regulation text as of October 2026. Medicare claim appeals follow a different five-level process under other rules; White Glove Medical Billing, a separate company, describes those in the five levels of Medicare appeal.

Who can ask for an ALJ hearing?

Section 498.5(l) covers enrollment. A prospective or existing provider or supplier "dissatisfied with a reconsidered determination" on the denial or revocation of billing privileges "is entitled to a hearing before an ALJ." The same paragraph gives CMS and its contractors the same right, so a reconsideration you win can be appealed by the government. Section 498.5(n) gives the same ladder to anyone placed on the Medicare preclusion list.

One limit: for denials based on a temporary enrollment moratorium, review "will be limited to whether the temporary moratorium applies to the provider or supplier appealing the denial" (498.5(l)(4)). The moratorium itself cannot be challenged.

When is the hearing request due?

Under 42 CFR 498.40(a)(2), the affected party "must file the request in writing within 60 days from receipt of the notice of initial, reconsidered, or revised determination." Receipt is presumed under the same rule used at reconsideration: 5 days after the date on the notice (498.22(b)(3)). The request goes to "the ALJ office identified in the determination letter" (498.40(a)(1)).

The request must "identify the specific issues, and the findings of fact and conclusions of law with which the affected party disagrees" and "specify the basis for contending that the findings and conclusions are incorrect" (498.40(b)). If you are late, 498.40(c) allows a written request for an extension, which the ALJ may grant "for good cause shown."

Can you bring new evidence to the ALJ?

Only with good cause. Section 498.56(e) sets a special rule for enrollment appeals: before the hearing, the ALJ examines any new documentary evidence "to determine whether the provider or supplier has good cause for submitting the evidence for the first time at the ALJ level." If there is no good cause, the ALJ "must exclude the evidence from the proceeding and may not consider it in reaching a decision." This matches 42 CFR 405.803(e), which bars new evidence at higher levels when it was not submitted before the reconsideration decision. Our post on Medicare enrollment denials and reconsideration explains why the first record matters so much.

How fast must the ALJ decide?

For an appeal of a denied enrollment application, 42 CFR 498.79 requires the ALJ to "issue a decision, dismissal order or remand to CMS, as appropriate, no later than the end of the 180-day period beginning from the date the appeal was filed." The text of 498.79 addresses denials of enrollment applications; it does not set the same clock for revocations.

What does the Departmental Appeals Board review?

Either party can ask the DAB to review the ALJ's decision or dismissal (498.80). Under 42 CFR 498.82(a)(2), the request must be filed "within 60 days from receipt of the notice of decision or dismissal, unless the Board, for good cause shown by the requesting party, extends the time for filing." It must specify the issues, the findings or conclusions you dispute, and why they are wrong (498.82(b)).

When the affected party asks, the Board grants review unless the request is withdrawn, untimely without good cause, outside the party's rights, or barred by an earlier final decision on the same facts (498.83(b)). Review is by a panel of at least two Board members and one individual designated from the U.S. Public Health Service (498.83(d)).

The evidence limit continues. Section 498.86(a) lets the Board admit additional evidence "except for provider or supplier enrollment appeals." For an appeal of an enrollment application denial filed after an ALJ decision, 498.88(g) requires the Board to decide, dismiss or remand "no later than 180 days after the appeal was received by the Board."

What comes after the Board?

The Board's decision is binding unless you timely file a civil action in federal district court (498.90). Under 42 CFR 498.95(a), you "must commence civil action within 60 days from receipt of the notice of the Board's decision," unless the Board extends the time; a request for extension must be filed in writing with the Board before the 60 days end. ALJ and Board decisions can also be reopened within 60 days of the notice of decision on a party's petition or on the decision maker's own motion (498.100).

What does the whole ladder look like?

1. Reconsideration: 60 days from receipt of the initial determination (498.22(b)(3)); CMS's manual counts 65 calendar days from the letter date.
2. ALJ hearing: 60 days from receipt of the reconsidered determination (498.40(a)(2)).
3. Departmental Appeals Board: 60 days from receipt of the ALJ decision or dismissal (498.82(a)(2)).
4. Federal district court: 60 days from receipt of the Board's decision (498.95(a)).

Payment is not made while any of this runs. If you win, 424.545(a)(2) lets you resubmit unpaid claims for services furnished during the overturned period.

Why should an attorney lead from this point?

An ALJ hearing is an adversarial proceeding with CMS as the other party, legal briefing, rules on admissible evidence and, later, judicial review. The regulations allow representatives, and 498.10 accepts an attorney's statement of authority without more. This is the point where the work becomes the practice of law. We do not represent providers, appear at hearings or write legal briefs, and we will tell you plainly when a matter has reached that stage.

How can we still help?

Attorneys bill by the hour, and a well-organized file saves hours. Before you hire counsel, we can assemble what they will ask for: the initial determination and reconsideration letters, a dated timeline, the full evidence package exactly as it was submitted at reconsideration, the regulatory paragraphs cited, and a deadline calendar for each level. That organizing work fits within a Network Rejection Review ($249) or a Payer Network Dispute ($799). You and your attorney decide what is filed, and you or your attorney sign and send it. See the pricing page for what each step includes.