[Federal Register Volume 84, Number 136 (Tuesday, July 16, 2019)]
[Notices]
[Pages 33956-33957]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-15151]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

[OMHA-1902-N]


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

AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This quarterly notice lists the OMHA Case Processing Manual 
(OCPM) instructions that were published from April through June 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].

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 April through June 
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 April Through June 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 April through June 
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 11: Procedural Review and Determinations

    This newly issued chapter describes how to conduct a procedural 
review of an appeal, and how to resolve any identified procedural 
defects. The procedural review is required to ensure that a request for 
hearing or review of dismissal meets jurisdictional and filing

[[Page 33957]]

requirements, and that procedural determinations are made before case 
development occurs, or a conference or hearing is scheduled. If there 
is a procedural defect, the defect may result in a dismissal or may 
require an opportunity for the appellant to resolve the defect. If an 
adjudication time frame applies to the case, a procedural defect may 
delay the start of, or extend, the adjudication time frame. When the 
procedural review is complete, and any identified defects have been 
resolved, and any applicable determinations have been made, the case 
moves forward in the adjudication process. Specialized procedural 
review is required for requests for expedited hearings in Part D 
appeals; however, a hearing may be scheduled before the screening is 
complete and any procedural defects are resolved, to facilitate meeting 
the expedited adjudication period.

OCPM Chapter 6: CMS, CMS Contractor, Plan Roles--Sections 6.3.1.1, 
6.3.2

    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). Sections 6.3.1.1 and 6.3.2 of this 
chapter state that a Unified Program Integrity Contractor (UPIC) cannot 
elect party status in an appeal, and may only participate as a non-
party. As initially published, these sections cited to CMS's Medicare 
Program Integrity Manual, internet-only manual publication 100-08, 
chapter 4, section 4.8.2, which previously stated that a Zone Program 
Integrity Contractor (ZPIC) could not elect party status in an appeal, 
and section 4.1, which stated that all references to ZPICs shall also 
apply to UPICs, unless otherwise specified in the UPIC Statement of 
Work (SOW). Effective October 22, 2018, CMS revised the Medicare 
Program Integrity Manual to directly state that a UPIC cannot invoke 
party status, and can only participate in OMHA proceedings as a non-
party. This revision to OCPM 6.3.1.1 and 6.3.2 updates footnotes in 
these sections to reflect the CMS manual's revised language. This 
revision does not change the way that OMHA interprets or implements the 
underlying policy that a UPIC cannot elect party status.

    Dated: July 2, 2019.
Karen W. Ames,
Executive Director, Office of Medicare Hearings and Appeals.
[FR Doc. 2019-15151 Filed 7-15-19; 8:45 am]
 BILLING CODE 4150-46-P