[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

[[Page 6584]]

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