[Federal Register Volume 80, Number 132 (Friday, July 10, 2015)]
[Notices]
[Pages 39785-39786]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-16824]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1501-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--March Through June 2015
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Notice.
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SUMMARY: This notice announces the implementation of the OMHA Case
Processing Manual (OCPM). This manual standardizes the day-to-day
procedures for carrying out adjudicative functions, in accordance with
applicable statutes, regulations and OMHA directives, and gives OMHA
staff direction for processing appeals at the OMHA level of
adjudication.
FOR FURTHER INFORMATION CONTACT: Jason Green, by telephone at (703)
235-0124, or by email at [email protected].
SUPPLEMENTARY INFORMATION:
I. Background
The Office of Medicare Hearings and Appeals (OMHA), a staff
division within the Office of the Secretary of the U.S. Department of
Health and Human Services (HHS), administers the nationwide
Administrative Law Judge hearing program for Medicare claim,
organization and coverage determination, and entitlement appeals under
sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of the
Social Security Act (the Act). OMHA ensures that Medicare beneficiaries
and the providers and suppliers that furnish items or services to
Medicare beneficiaries, as well as Medicare Advantage Organizations
(MAOs) and Medicaid State Agencies, have a fair and impartial forum to
address disagreements with Medicare coverage and payment determinations
made by Medicare contractors, MAOs, or Part D Plan Sponsors (PDPSs),
and determinations related to Medicare eligibility and entitlement,
Part B late enrollment penalty, and income-related monthly adjustment
amounts (IRMAA) made by the Social Security Administration (SSA).
The Medicare claim, organization and coverage determination appeals
processes consist of four levels of administrative review, and a fifth
level of review with the Federal district courts after administrative
remedies under HHS regulations have been exhausted. The first two
levels of review are administered by the Centers for Medicare &
Medicaid Services (CMS) and conducted by Medicare contractors for claim
appeals, by MAOs and an independent review entity for Part C
organization determination appeals, or by PDPSs and an independent
review entity for Part D coverage determination appeals. The third
level of review is administered by OMHA and conducted by Administrative
Law Judges. The fourth level of review is administered by the HHS
Departmental Appeals Board (DAB) and conducted by the Medicare Appeals
Council. In addition, OMHA and the DAB administer the second and third
levels of appeal, respectively, for Medicare eligibility, entitlement,
Part B late enrollment penalty, and IRMAA reconsiderations made by SSA;
a fourth level of review with the Federal district courts is available
after administrative
[[Page 39786]]
remedies within SSA and HHS have been exhausted.
Sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of
the Act are implemented through the regulations at 42 CFR part 405
subparts I and J; part 417, subpart Q; part 422, subpart M; part 423,
subparts M and U; and part 478, subpart B. As noted above, OMHA
administers the nationwide Administrative Law Judge hearing program in
accordance with these statutes and applicable regulations. As part of
that effort, OMHA is establishing a manual, the OMHA Case Processing
Manual (OCPM). Through the OCPM, the OMHA Chief Administrative Law
Judge establishes the day-to-day procedures for carrying out
adjudicative functions, in accordance with applicable statutes,
regulations and OMHA directives. The OCPM provides direction for
processing appeals at the OMHA level of adjudication for Medicare Part
A and B claims; Part C organization determinations; Part D coverage
determinations; and SSA eligibility and entitlement, Part B late
enrollment penalty, and IRMAA determinations.
Section 1871(c) of the Act requires that we publish a list of all
Medicare manual instructions, interpretive rules, statements of policy,
and guidelines of general applicability not issued as regulations at
least every 3 months in the Federal Register.
II. Format for the Quarterly Issuance Notices
This quarterly notice announces the publication of the initial OCPM
chapters. A hyperlink to the available chapters on the OMHA Web site is
provided below. The OMHA Web site contains the most current, up-to-date
chapters and revisions to chapters, and will be available earlier than
we publish our quarterly notice. We believe the OMHA Web site list
provides more timely access to the current OCPM chapters for those
involved in the Medicare claim, organization and coverage determination
and entitlement appeals processes. We also believe the Web site offers
the public a more convenient tool for real time access to current OCPM
provisions. In addition, OMHA has a listserv to which the public can
subscribe to receive immediate notification of any updates to the OMHA
Web site. This listserv avoids the need to check the OMHA Web site, as
update notifications are sent to subscribers as they occur. If
accessing the OMHA Web site proves to be difficult, the contact person
listed above can provide the information.
III. How To Use the Notice
This notice lists the OCPM chapters and subjects published during
the quarter covered by the notice so the reader may determine whether
any are of particular interest. We expect this notice to be used in
concert with future published notices. The OCPM can be accessed at
http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.
IV. OCPM Releases for March Through June 2015
The OCPM is used by OMHA adjudicators and staff to administer the
OMHA program. It offers day-to-day operating instructions, policies,
and procedures based on statutes and regulations, and OMHA directives.
The following is a list and description of new OCPM provisions and
the subject matter. For future quarterly notices, we will list only the
specific updates to the list of manual provisions that have occurred in
the covered 3-month period. This information is available on our Web
site at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.
OCPM Division I: General Matters
Chapter 1, Manual Overview, Definitions, Governance. This new
chapter provides a general overview of the OCPM, including the purpose
of the manual, how it is organized and used, a list of acronyms and
abbreviations used in the manual, and how manual provisions will be
updated.
OCPM Division II: Part A/B Claim Determinations
Chapter 3, Procedural Screening. This new chapter describes the
review process for new requests for hearing on Medicare Part A and Part
B reconsiderations issued by Qualified Independent Contractors (QICs)
and Quality Improvement Organizations (QIOs), and escalations of
requests for reconsideration by a QIC. The review process helps ensure
requests are complete and jurisdictional requirements are met.
OCPM Division III: Part C Organization Determinations
Chapter 3, Procedural Screening. This new chapter describes the
review process for new requests for hearing on Medicare Part C
reconsiderations issued by an Independent Review Entity and QIOs. The
review process helps ensure requests are complete and jurisdictional
requirements are met.
OCPM Division IV: Part D Coverage Determinations
Chapter 3, Procedural Screening. This new chapter describes the
review process for new requests for hearing on Medicare Part D
reconsiderations issued by an Independent Review Entity. The review
process helps ensure requests are complete and jurisdictional
requirements are met.
OCPM Division V: SSA Determinations
Chapter 3, Procedural Screening. This new chapter describes the
review process for new requests for hearing on reconsiderations of
Medicare eligibility and entitlement, Part B late enrollment penalties,
and Part B and Part D IRMAAs issued by SSA. The review process helps
ensure requests are complete and jurisdictional requirements are met.
Dated: June 30, 2015.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of Medicare Hearings and
Appeals.
[FR Doc. 2015-16824 Filed 7-9-15; 8:45 am]
BILLING CODE 4152-01-P