[Federal Register Volume 85, Number 127 (Wednesday, July 1, 2020)]
[Notices]
[Pages 39571-39573]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-14203]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1903-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--October 2019 Through March 2020
AGENCY: Office of Medicare Hearings and Appeals (OMHA), Health and
Human Services (HHS).
ACTION: Notice.
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SUMMARY: This notice lists the OMHA Case Processing Manual (OCPM)
instructions that were published from October 2019 through March 2020.
This
[[Page 39572]]
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 notice provides the specific updates to the OCPM that have
occurred in the period of October 2019 through March 2020. 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 period 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 October 2019 Through March 2020
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 period of October 2019 through March
2020. 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 16: Decisions
On October 9, 2019, OMHA issued OCPM Chapter 16, which describes
the structure and content of the decisions issued by OMHA adjudicators.
The chapter details when an adjudicator classifies a decision as
favorable or fully favorable, unfavorable, or partially favorable, and
the effect the financial responsibility determination has on the
characterization of the decision. Additionally, the chapter provides
general writing guidelines and the protocols for protecting personally
identifiable and protected health information in a decision. The
chapter also describes the format for a decision affirming the
dismissal of a request for reconsideration, a decision addressing
multiple consolidated appeals, and a stipulated decision. An OMHA-
approved notice of decision template must accompany every decision and
describes the parties' appeals rights. OMHA also issued a Citation
Policy as chapter support material to Chapter 16.
OCPM Chapter 15: Conducting Conferences and Hearings: Posthearing
Development
On November 21, 2019, OMHA issued OCPM Chapter 15, which describes
the process used by OMHA adjudicators when conducting prehearing/
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posthearing conferences and hearings. The chapter details regulatory
requirements, OMHA administrative requirements, and suggested best
practices when conducting a conference or hearing. The chapter also
explains when and how to hold a consolidated, supplemental, or
continued hearing; the procedures for responding to a request for a
copy of the administrative record; and available actions that can be
taken to develop the administrative record after an initial hearing has
been conducted.
OCPM Chapter 10: Party and Non-Party Participant Requests and
Submissions
On February 19, 2020, OMHA issued OCPM Chapter 10, which explains
how to route, document and address contacts from parties and non-party
participants involving both general and case-specific matters. The
chapter describes how to provide language or communication assistance
services to individuals with limited English proficiency or a
disability, and summarizes the services OMHA offers in response to such
requests. The chapter also explains how to process requests for a stay
of proceedings, discovery, or subpoena; and review submissions of
evidence and other case-related materials. Many types of requests and
submissions that generally occur at a specific stage in the
adjudication process are covered in detail in other OCPM chapters. To
facilitate locating this information, Chapter 10 contains a list of
these requests and submissions, along with cross-references to the
specific OCPM provisions where they are discussed.
Dated: June 26, 2020.
Karen W. Ames,
Executive Director, Office of Medicare Hearings and Appeals.
[FR Doc. 2020-14203 Filed 6-30-20; 8:45 am]
BILLING CODE 4150-46-P