[Federal Register Volume 88, Number 248 (Thursday, December 28, 2023)]
[Notices]
[Pages 89710-89711]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-28625]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

[OMHA-2302-N]


Medicare Program; Administrative Law Judge Hearing Program for 
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program 
Issuances--July Through September 2023

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 
2023. 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: Jon Dorman, by telephone at (571) 457-
7220, 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 July through September 
2023. 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

[[Page 89711]]

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 July Through September 2023

    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 July through 
September 2023. 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 20 (Post-Adjudication Actions) Updates

    OMHA issued the initial version of this chapter on May 25, 2018, 
and included it in a quarterly notice published in the August 7, 2018 
Federal Register (83 FR 38700). The revised chapter addresses changes 
to post-adjudication appeals processing resulting from increased 
electronic case processing through OMHA's Electronic Case Adjudication 
and Processing Environment (ECAPE), advances in appeal filing 
procedures through the e-Appeal Portal, and other improvements in 
appeals operations and processing. This revision removes outdated data 
entry processes that were updated with electronic case processing. This 
revision also clarifies how post-adjudication actions are processed if 
the original adjudicator is not available for more than 20 calendar 
days; clarifies how various post-adjudication requests are filed; 
updates the operational process to re-establish an appeal. Finally, the 
revision adds a new section, 20.13, Requests to Obtain Approval of a 
Fee, which incorporates information previously included in OCPM Chapter 
5. OMHA made revisions in the following sections: 20.2.1, 20.2.2, 
20.3.2, 20.3.4, 20.4.1, 20.4.3, 20.4.4, 20.4.5, 20.4.6, 20.5.2, 20.5.3, 
20.5.4, 20.5.5 (multiple), 20.5.7 (multiple), 20.5.8 (multiple), 20.6.1 
(multiple), 20.6.2, 20.6.4, 20.6.5 (multiple), 20.6.6.1, 20.6.7 
(multiple), 20.7.1.4, 20.7.2, 20.7.4, 20.7.5 (multiple), 20.7.7 
(multiple), 20.8.1.3, 20.8.2, 20.8.4, 20.8.5 (multiple), 20.8.6.1, 
20.8.7 (multiple), 20.9.1, 20.9.2, 20.9.4, 20.9.5, 20.10.2, 20.10.3, 
20.11.2, 20.11.4, 20.11.5, 20.11.6, 20.12.1, 20.12 (multiple), 20.13.

Karen W. Ames,
Executive Director of Operations, Office of Medicare Hearings and 
Appeals.
[FR Doc. 2023-28625 Filed 12-27-23; 8:45 am]
BILLING CODE 4150-46-P