[Federal Register Volume 82, Number 12 (Thursday, January 19, 2017)]
[Notices]
[Pages 6583-6584]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-01181]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1602-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--October Through December 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 October through
December, 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
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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 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 October Through December 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 or revised 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 6, CMS and CMS Contractor Roles. We corrected a misdirected
link to the CMS Medicare Administrative Contractors Web site (https://www.cms.gov/medicare/medicare-contracting/medicare-administrative-contractors/medicareadministrativecontractors.html) in the table in
Section I-6-1 of this chapter.
OCPM Division II: Part A/B Claim Determinations
Chapter 3, Procedural Screening. The table in Section II-3-4 A of
this chapter was updated to include the minimum amounts in controversy
(AICs) required for an Administrative Law Judge hearing for calendar
years through 2017.
OCPM Division III: Part C Organization Determinations
Chapter 3, Procedural Screening. The table in Section III-3-4 A of
this chapter was updated to include the minimum AICs required for an
Administrative Law Judge hearing for calendar years through 2017.
OCPM Division IV: Part D Organization Determinations
Chapter 3, Procedural Screening. The table in Section IV-3-4 A of
this chapter was updated to include the minimum AICs required for an
Administrative Law Judge hearing for calendar years through 2017.
OCPM Division V: SSA Determinations
Chapter 3, Procedural Screening. The table in Section V-3-4 A of
this chapter was updated to include the minimum AICs required for an
Administrative Law Judge hearing for calendar years through 2017.
Dated: January 6, 2017.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2017-01181 Filed 1-18-17; 8:45 am]
BILLING CODE 4152-01-P