[Federal Register Volume 81, Number 155 (Thursday, August 11, 2016)]
[Notices]
[Pages 53150-53151]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-18665]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1601-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--March Through June 2016
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Notice.
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SUMMARY: This quarterly notice lists the OMHA Case Processing Manual
(OCPM) manual instructions that were published from March through June,
2016. 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), Medicaid State Agencies, and applicable plans 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
[[Page 53151]]
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 2016
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 II: Part A/B Claim Determinations
Chapter 6, Pre-Hearing Case Development. This new chapter describes
the pre-hearing case development process for 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
pre-hearing case development process helps identify and address
evidentiary issues prior to the hearing to avoid delays and helps to
ensure legal requirements related to new evidence are observed. The
process also assists staff in determining whether a hearing is
necessary for a given case. In addition, the process guides OMHA staff
on processes available to facilitate the hearing process, such as
identifying special needs for hearing participants, discovery, using
experts, and conducting pre-hearing conferences.
Dated: July 15, 2016.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2016-18665 Filed 8-10-16; 8:45 am]
BILLING CODE 4152-01-P