[Federal Register Volume 84, Number 86 (Friday, May 3, 2019)]
[Notices]
[Pages 19086-19088]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-09008]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

[OMHA-1901-N]


Medicare Program; Administrative Law Judge Hearing Program for 
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program 
Issuances--January Through March 2019

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 January through March 
2019. 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].

[[Page 19087]]


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 (IRE) for Part C organization determination 
appeals, or by PDPSs and an IRE 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 January through March 
2019. 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. 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 January Through March 2019

    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 issued or revised in the three-month period of January through 
March 2019. 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 4: Parties

    The parties to an OMHA appeal are specified by regulation and vary 
based on the matter presented and the Medicare Part under which the 
appeal arises. This newly issued chapter identifies: (1) The different 
parties and potential parties to an appeal; (2) when an individual or 
entity may enter the proceedings as a substitute party; (3) when and 
how a beneficiary's appeal rights may be assigned to a provider or 
supplier; and (4) the procedures OMHA follows when an appellant's party 
status is unclear. There may be multiple parties to an appeal, and an 
individual's or entity's party status is generally not determined by 
the individual's or entity's financial interest in the outcome of the 
appeal, unless otherwise noted in this chapter.

OCPM Chapter 7: Adjudication Time Frames, Case Prioritization, and 
Escalations--Section 7.4.3

    This chapter was initially released on July 27, 2018, and was 
included in a quarterly notice published in the November 14, 2018 
Federal Register (83 FR 56859). After the initial publication, we 
discovered that certain language from OMHA's existing case 
prioritization policy had been inadvertently omitted when the policy 
was transferred to the OCPM. This revision to OCPM 7.4.3 corrects this 
error by clarifying that, if a beneficiary is represented by another 
party or by the same representative as another party, OMHA treats the 
beneficiary's case as a Priority 3 appeal (see OCPM 7.4.2), unless: (1) 
The beneficiary is or would

[[Page 19088]]

be liable for the costs (other than deductibles and coinsurance) of the 
items or services in dispute; (2) the case involves a pre-service 
request for coverage; or (3) one of the exceptions in OCPM 7.4.4 
applies. The error we corrected was purely administrative, and had no 
effect on the manner in which OMHA prioritizes appeals.

OCPM Chapter 9: Request and Correspondence Intake, Docketing, and 
Assignment

    A number of actions may initiate (or reinitiate) proceedings at the 
OMHA level. This newly issued chapter provides information on where to 
direct appeal requests and submissions, and details the processes for 
docketing, acknowledging, and assigning cases. This chapter also 
explains when claims may be added or removed from an appeal and how to 
combine appeals. While this chapter deals primarily with processing 
appeals as paper files, it also includes guidelines for processing 
electronic case files in OMHA's Electronic Case Adjudication Processing 
Environment (ECAPE).

OCPM Chapter 19: Closing the Case--Sections 19.4.3, 19.5.1

    This chapter was initially released on May 25, 2018, and was 
included in a quarterly notice published in the August 7, 2018 Federal 
Register (83 FR 38700). This revision to OCPM 19.4.3 clarifies that, in 
accordance with 42 CFR 405.1044(b) and 423.2044(b), if an adjudicator 
issues a consolidated decision, the adjudicator must also consolidate 
the administrative record and combine the appeals in the case 
processing system. OCPM 19.5.1 was also revised, to clarify that, when 
an appeal involves multiple beneficiaries, any copies of disposition 
documents (for example, a decision and any accompanying notices or 
enclosures), must be redacted to display only personally identifiable 
information (PII) that the recipient is entitled to receive.

    Dated: April 25, 2019.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2019-09008 Filed 5-2-19; 8:45 am]
BILLING CODE 4150-46-P