[Federal Register Volume 83, Number 220 (Wednesday, November 14, 2018)]
[Notices]
[Pages 56859-56860]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-24722]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1802-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--July Through September 2018
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) instructions that were published from July through September
2018. 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 (571)
777-2723, 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 within the U.S. Department
of Health and Human Services (HHS), administers the nationwide
Administrative Law Judge hearing program for Medicare claim;
organization, coverage, and at-risk 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 determination, coverage
determination, and at-risk 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 and at-risk determination appeals. The third
level of review is administered by OMHA and conducted by Administrative
Law Judges and attorney adjudicators. The fourth level of review is
administered by the HHS Departmental Appeals Board (DAB) and conducted
by the Medicare Appeals Council (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. To help
ensure nationwide consistency in that effort, OMHA established a
manual, the 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 at-risk determinations; and SSA eligibility and
entitlement, Part B late enrollment penalty, and IRMAA determinations.
Section 1871(c) of the Act requires that the Secretary 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 three 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 three-month period of July through September
2018. A hyperlink to the available chapters on the OMHA website is
provided below. The OMHA website 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 website provides
more timely access to the current OCPM chapters for those involved in
the Medicare claim; organization, coverage, and at-risk determination;
and entitlement appeals processes. We also believe the website 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 notification of certain updates to the OMHA
website, including when new or revised OCPM chapters are posted. If
accessing the OMHA website 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
https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html.
IV. OCPM Releases for July Through September 2018
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 OCPM provisions that
were revised in the three-month period of July through September 2018.
This information is available on our website at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html.
OCPM Chapter 5: Representatives
Chapter 5, Representatives. This chapter describes the role of
representatives in the appeals process, including the documentation
required
[[Page 56860]]
to establish a valid representation, representative rights and
responsibilities, communications with representatives and represented
parties, and changes of representative due to delegation, revocation,
or termination of an appointment. This chapter also discusses the fee
approval process for representatives and the circumstances under which
an eligible individual or entity may be entitled to reasonable attorney
fees and other expenses under the Equal Access to Justice Act.
OCPM Chapter 6: CMS, CMS Contractor, and Plan Roles
Chapter 6, CMS, CMS Contractor, and Plan Roles. This chapter
describes when and how CMS, a CMS contractor, or a plan (for example, a
Medicare Advantage organization or Part D plan sponsor) may join the
proceedings on a request for hearing as a party or as a non-party
participant. This chapter also describes the requirements for a valid
election or request to participate in the proceedings, and the
circumstances under which an election may be deemed invalid or a
request may be denied. This chapter also discusses when evidence,
position papers, and written testimony may be submitted by CMS, a CMS
contractor, or a plan.
OCPM Chapter 7: Adjudication Time Frames, Case Prioritization, and
Escalations
Chapter 7, Adjudication Time Frames, Case Prioritization, and
Escalations. This chapter describes the time frames for an adjudicator
to issue a decision, dismissal, or remand in an appeal. This chapter
also addresses when an adjudication time frame may be delayed or
extended, and how it can be waived by the appellant. This chapter
discusses OMHA's case prioritization policy, which determines the
general order in which appeals are processed. Lastly, this chapter
describes the types of appeal that may be escalated to the Medicare
Appeals Council when an adjudicator is unable to issue a decision,
dismissal, or remand within an applicable adjudication time frame, and
the requirements for a valid request for escalation.
OCPM Chapter 14: Scheduling and Noticing for Prehearing Conferences and
Hearings
Chapter 14, Scheduling and Noticing for Prehearing Conferences and
Hearings. This chapter describes the process for scheduling and
providing notice of prehearing conferences and hearings, the actions
that must be completed before a hearing is scheduled, and the
circumstances when a hearing is required. This chapter also identifies
the parties, potential parties, and participants to whom notices must
be sent, and how to address responses to these notices and any
objections or requests that may be made by the notice recipients.
Finally, this chapter discusses the circumstances in which a hearing
may be rescheduled or canceled, and when a supplemental hearing may be
necessary.
Dated: November 6, 2018.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2018-24722 Filed 11-13-18; 8:45 am]
BILLING CODE 4150-46-P