[Federal Register Volume 81, Number 35 (Tuesday, February 23, 2016)]
[Notices]
[Pages 8969-8970]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-03634]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1503-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--October Through December 2015
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Notice.
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SUMMARY: This quarterly notice lists of the OMHA Case Processing Manual
(OCPM) manual instructions that were published from October through
December, 2015. 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: Amanda Axeen, by telephone at (571)
777-2705, 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 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 provides the specific updates to the OCPM
that have occurred in the 3-month period. 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
[[Page 8970]]
reader may determine whether any are of particular interest. We expect
this notice to be used in concert with the previously published
notices. The OCPM can be accessed at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.
IV. OCPM Releases for October Through December 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 that have been implemented in the covered 3-month
period. The full text of current OCPM provisions is available on our
Web site at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.
OCPM Division I: General Matters
Chapter 7, Adjudication Time Frames. This new chapter describes the
cases subject to statutory time frames, tolling and waivers of
adjudication time frames, and provides instruction on how to handle
cases escalated from the Qualified Independent Contractor (QIC) to OMHA
and from OMHA to the Medicare Appeals Council.
OCPM Division II: Part A/B Claim Determinations
Chapter 4, Administrative Record. This new chapter describes the
minimum organization and exhibiting structure for documents and
evidence received in support of Medicare Part A and B requests for
hearing filed with OMHA. This chapter standardizes the way that OMHA
prepares these files for further processing.
Chapter 7, Scheduling and Notices of Hearing. This new chapter
describes the scheduling and notice of hearing process in Medicare Part
A and Part B cases and provides guidance on sending amended notices of
hearing, rescheduling or cancelling hearings and issuing notices for
supplemental hearings.
Chapter 13, Closing the Case. This new chapter describes the
necessary administrative steps to finalize and close a Medicare Part A
or Part B case. The chapter also provides guidance on mailing the
notice of disposition and shipping the case file.
OCPM Division III: Part C Organization Determinations
Chapter 4, Administrative Record. This new chapter describes the
minimum organization and exhibiting structure for documents and
evidence received in support of Medicare Part C requests for hearing
filed with OMHA. This chapter standardizes the way that OMHA prepares
these files for further processing.
Chapter 7, Scheduling and Notices of Hearing. This new chapter
describes the scheduling and notice of hearing process in Medicare C
cases and provides guidance on sending amended notices of hearing,
rescheduling or cancelling hearings and issuing notices for
supplemental hearings.
Chapter 13, Closing the Case. This new chapter describes the
necessary administrative steps to finalize and close a Medicare Part C
case. The chapter also provides guidance on mailing the notice of
disposition and shipping the case file.
OCPM Division IV: Part D Coverage Determinations
Chapter 4, Administrative Record. This new chapter describes the
minimum organization and exhibiting structure for documents and
evidence received in support of Medicare Part D requests for hearing
filed with OMHA. This chapter standardizes the way that OMHA prepares
these files for further processing.
Chapter 7, Scheduling and Notices of Hearing. This new chapter
describes the scheduling and notice of hearing process in Medicare D
cases and provides guidance on sending amended notices of hearing,
rescheduling or cancelling hearings and issuing notices for
supplemental hearings.
Chapter 13, Closing the Case. This new chapter describes the
necessary administrative steps to finalize and close a Medicare Part D
case. The chapter also provides guidance on mailing the notice of
disposition and shipping the case file.
OCPM Division V: SSA Determinations
Chapter 4, Administrative Record. This new chapter describes the
minimum organization and exhibiting structure for documents and
evidence received in support of requests for hearing filed with OMHA
following reconsiderations of Medicare eligibility and entitlement,
Part B late enrollment penalties, and Part B and Part D IRMAAs issued
by SSA. This chapter standardizes the way that OMHA prepares these
files for further processing.
Chapter 7, Scheduling and Notices of Hearing. This new chapter
describes the scheduling and notice of hearing process for requests for
hearing filed following reconsideration of Medicare eligibility and
entitlement, Part B late enrollment penalties, and Part B and Part D
IRMAAs issued by SSA. The chapter also provides guidance on sending
amended notices of hearing, rescheduling or cancelling hearings and
issuing notices for supplemental hearings.
Chapter 13, Closing the Case. This new chapter describes the
necessary administrative steps to finalize and close a case on appeal
at OMHA following reconsideration of Medicare eligibility and
entitlement, Part B late enrollment penalties, and Part B and Part D
IRMAAs issued by SSA. The chapter also provides guidance on mailing the
notice of disposition and shipping the case file.
Dated: February 8, 2016.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2016-03634 Filed 2-22-16; 8:45 am]
BILLING CODE 4152-01-P