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:

Access the IRMAA Appeals Tracking System:

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  Click on Establish/Update/Delete Appeal.

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  Enter the Beneficiary’s own SSN (do not enter the claim number) and click the Search button.

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  Click in the YES radio button to enter a new appeal, then click Continue.

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  Enter your unit code, the beneficiary’s first name, middle initial and last name. Click Continue.

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  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.

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  Date Appeal Filed – Enter the date the beneficiary requested the hearing.

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  Select Event – Select the type of event the beneficiary is appealing. They can appeal the Initial Determination, LCE, More Recent Tax Information or Non-Qualifying Event.

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  Date of the Event – Enter the date of the event being appealed.

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  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.

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  Reason For Appeal – Select the reason the beneficiary is filing the appeal.

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  Select Level of Appeal - ALJ.

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  Rep or Attorney – Select “Yes” if the beneficiary has a representative or attorney.

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  Good Cause – The Good Cause button is grayed out for appeals above the Reconsideration level.

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  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.

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  Click continue.

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  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.

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  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.

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  Enter Destination Office Code- Enter C34.

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  Enter Reason for Transfer – Add a message in this free format field.

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  Click Transfer Case button.

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  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