[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