[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