80_FR_39917 80 FR 39785 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-March Through June 2015

80 FR 39785 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-March Through June 2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Federal Register Volume 80, Issue 132 (July 10, 2015)

Page Range39785-39786
FR Document2015-16824

This notice announces the implementation of the OMHA Case Processing Manual (OCPM). 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.

Federal Register, Volume 80 Issue 132 (Friday, July 10, 2015) 
[Federal Register Volume 80, Number 132 (Friday, July 10, 2015)]
[Notices]
[Pages 39785-39786]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2015-16824]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

[OMHA-1501-N]


Medicare Program; Administrative Law Judge Hearing Program for 
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program 
Issuances--March Through June 2015

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

ACTION: Notice.

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SUMMARY: This notice announces the implementation of the OMHA Case 
Processing Manual (OCPM). 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 (703) 
235-0124, 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 of the U.S. Department of 
Health and Human Services (HHS), administers the nationwide 
Administrative Law Judge hearing program for Medicare claim, 
organization and coverage 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) and Medicaid State Agencies, 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 and coverage 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 appeals. The third 
level of review is administered by OMHA and conducted by Administrative 
Law Judges. The fourth level of review is administered by the HHS 
Departmental Appeals Board (DAB) and conducted by the Medicare Appeals 
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

[[Page 39786]]

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. As part of 
that effort, OMHA is establishing a manual, the OMHA Case Processing 
Manual (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 SSA eligibility and entitlement, Part B late 
enrollment penalty, and IRMAA determinations.
    Section 1871(c) of the Act requires that we 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 3 months in the Federal Register.

II. Format for the Quarterly Issuance Notices

    This quarterly notice announces the publication of the initial OCPM 
chapters. A hyperlink to the available chapters on the OMHA Web site is 
provided below. The OMHA Web site 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 Web site list 
provides more timely access to the current OCPM chapters for those 
involved in the Medicare claim, organization and coverage determination 
and entitlement appeals processes. We also believe the Web site 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 immediate notification of any updates to the OMHA 
Web site. This listserv avoids the need to check the OMHA Web site, as 
update notifications are sent to subscribers as they occur. If 
accessing the OMHA Web site 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 
http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.

IV. OCPM Releases for March Through June 2015

    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 new OCPM provisions and 
the subject matter. For future quarterly notices, we will list only the 
specific updates to the list of manual provisions that have occurred in 
the covered 3-month period. This information is available on our Web 
site at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.

OCPM Division I: General Matters

    Chapter 1, Manual Overview, Definitions, Governance. This new 
chapter provides a general overview of the OCPM, including the purpose 
of the manual, how it is organized and used, a list of acronyms and 
abbreviations used in the manual, and how manual provisions will be 
updated.

OCPM Division II: Part A/B Claim Determinations

    Chapter 3, Procedural Screening. This new chapter describes the 
review process for new requests for hearing on Medicare Part A and Part 
B reconsiderations issued by Qualified Independent Contractors (QICs) 
and Quality Improvement Organizations (QIOs), and escalations of 
requests for reconsideration by a QIC. The review process helps ensure 
requests are complete and jurisdictional requirements are met.

OCPM Division III: Part C Organization Determinations

    Chapter 3, Procedural Screening. This new chapter describes the 
review process for new requests for hearing on Medicare Part C 
reconsiderations issued by an Independent Review Entity and QIOs. The 
review process helps ensure requests are complete and jurisdictional 
requirements are met.

OCPM Division IV: Part D Coverage Determinations

    Chapter 3, Procedural Screening. This new chapter describes the 
review process for new requests for hearing on Medicare Part D 
reconsiderations issued by an Independent Review Entity. The review 
process helps ensure requests are complete and jurisdictional 
requirements are met.

OCPM Division V: SSA Determinations

    Chapter 3, Procedural Screening. This new chapter describes the 
review process for new requests for hearing on reconsiderations of 
Medicare eligibility and entitlement, Part B late enrollment penalties, 
and Part B and Part D IRMAAs issued by SSA. The review process helps 
ensure requests are complete and jurisdictional requirements are met.

    Dated: June 30, 2015.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of Medicare Hearings and 
Appeals.
[FR Doc. 2015-16824 Filed 7-9-15; 8:45 am]
 BILLING CODE 4152-01-P

Federal Register / Vol. 80, No. 132 / Friday, July 10, 2015 / Notices 39785 proposed information collection for the Proposed Project: Examining this study will offer a wide-ranging view proper performance of the agency’s Consumer and Producer Responses to of the consumer and producer response functions; (2) the accuracy of the Restaurant Menu Labeling to menu labeling requirements. estimated burden; (3) ways to enhance Requirements: Survey Protocol—OMB ASPE is requesting comment on the the quality, utility, and clarity of the No. 0990–XXXX—New—Office of the burden for this study aimed at information to be collected; and (4) the Assistant Secretary for Planning and understanding the impact that the new use of automated collection techniques Evaluation (ASPE). or other forms of information Abstract: The Office of the Assistant FDA rule on calorie labeling will have technology to minimize the information Secretary for Planning and Evaluation on consumer choice when ordering from collection burden. (ASPE) is requesting approval on a new a restaurant. The goal of developing this To obtain copies of the supporting information collection request from the activity is to examine consumer and statement and any related forms for the Office of Management and Budget producer responses to restaurant menu proposed paperwork collections (OMB) for purposes of conducting a labeling requirements recently enacted referenced above, email your request, study about calorie labeling on by the FDA. The participants will including your address, phone number, restaurant menus. include members of the RAND OMB number, and OS document Previous research demonstrates that American Life Panel (ALP) which identifier, to Sherette.funncoleman@ consumers respond both to information includes participants from several hhs.gov, or call the Reports Clearance about their options and the way those sources, including the University of Office at (202) 690–6162. Written options are presented. Accordingly, Michigan Monthly Survey, the National comments and recommendations for the restaurants can utilize presentation Survey Project cohort, and several proposed information collections must effects on menus and menu boards to specific recruitment methods to add be directed to the OS Paperwork influence consumer perceptions and specific populations (e.g. active Clearance Officer at the above email choices. By analyzing the consumer recruitment for vulnerable populations). address within 60 days. response to menu options and design, ESTIMATED ANNUALIZED BURDEN TABLE Number of Average Number of responses burden per Total burden Type of respondent respondents per response hours respondent (in hours) ALP Panel Member ......................................................................................... 2,100 1 20/60 700 Totals ........................................................................................................ ........................ ........................ ........................ 700 Darius Taylor, 0124, or by email at jason.green@ made by the Social Security Paperwork Reduction Act Reports Clearance hhs.gov. Administration (SSA). Officer. SUPPLEMENTARY INFORMATION: The Medicare claim, organization and [FR Doc. 2015–16871 Filed 7–9–15; 8:45 am] coverage determination appeals BILLING CODE 4150–05–P I. Background processes consist of four levels of The Office of Medicare Hearings and administrative review, and a fifth level Appeals (OMHA), a staff division within of review with the Federal district DEPARTMENT OF HEALTH AND the Office of the Secretary of the U.S. courts after administrative remedies HUMAN SERVICES Department of Health and Human under HHS regulations have been [OMHA–1501–N] Services (HHS), administers the exhausted. The first two levels of review nationwide Administrative Law Judge are administered by the Centers for Medicare Program; Administrative Law Medicare & Medicaid Services (CMS) hearing program for Medicare claim, Judge Hearing Program for Medicare and conducted by Medicare contractors organization and coverage Claim and Entitlement Appeals; for claim appeals, by MAOs and an determination, and entitlement appeals Quarterly Listing of Program independent review entity for Part C under sections 1869, 1155, Issuances—March Through June 2015 organization determination appeals, or 1876(c)(5)(B), 1852(g)(5), and 1860D– AGENCY: Office of Medicare Hearings 4(h) of the Social Security Act (the Act). by PDPSs and an independent review and Appeals (OMHA), HHS. OMHA ensures that Medicare entity for Part D coverage determination ACTION: Notice. beneficiaries and the providers and appeals. The third level of review is suppliers that furnish items or services administered by OMHA and conducted SUMMARY: This notice announces the to Medicare beneficiaries, as well as by Administrative Law Judges. The implementation of the OMHA Case Medicare Advantage Organizations fourth level of review is administered by Processing Manual (OCPM). This (MAOs) and Medicaid State Agencies, the HHS Departmental Appeals Board manual standardizes the day-to-day have a fair and impartial forum to (DAB) and conducted by the Medicare procedures for carrying out adjudicative Appeals Council. In addition, OMHA mstockstill on DSK4VPTVN1PROD with NOTICES address disagreements with Medicare functions, in accordance with coverage and payment determinations and the DAB administer the second and applicable statutes, regulations and made by Medicare contractors, MAOs, third levels of appeal, respectively, for OMHA directives, and gives OMHA or Part D Plan Sponsors (PDPSs), and Medicare eligibility, entitlement, Part B staff direction for processing appeals at determinations related to Medicare late enrollment penalty, and IRMAA the OMHA level of adjudication. eligibility and entitlement, Part B late reconsiderations made by SSA; a fourth FOR FURTHER INFORMATION CONTACT: enrollment penalty, and income-related level of review with the Federal district Jason Green, by telephone at (703) 235– monthly adjustment amounts (IRMAA) courts is available after administrative VerDate Sep<11>2014 19:51 Jul 09, 2015 Jkt 235001 PO 00000 Frm 00041 Fmt 4703 Sfmt 4703 E:\FR\FM\10JYN1.SGM 10JYN1

39786 Federal Register / Vol. 80, No. 132 / Friday, July 10, 2015 / Notices remedies within SSA and HHS have III. How To Use the Notice OCPM Division IV: Part D Coverage been exhausted. Determinations Sections 1869, 1155, 1876(c)(5)(B), This notice lists the OCPM chapters and subjects published during the Chapter 3, Procedural Screening. This 1852(g)(5), and 1860D–4(h) of the Act new chapter describes the review are implemented through the quarter covered by the notice so the reader may determine whether any are process for new requests for hearing on regulations at 42 CFR part 405 subparts Medicare Part D reconsiderations issued I and J; part 417, subpart Q; part 422, of particular interest. We expect this notice to be used in concert with future by an Independent Review Entity. The subpart M; part 423, subparts M and U; review process helps ensure requests are and part 478, subpart B. As noted above, published notices. The OCPM can be accessed at http://www.hhs.gov/omha/ complete and jurisdictional OMHA administers the nationwide requirements are met. Administrative Law Judge hearing OMHA_Case_Processing_Manual/ program in accordance with these index.html. OCPM Division V: SSA Determinations statutes and applicable regulations. As IV. OCPM Releases for March Through Chapter 3, Procedural Screening. This part of that effort, OMHA is establishing June 2015 new chapter describes the review a manual, the OMHA Case Processing process for new requests for hearing on Manual (OCPM). Through the OCPM, The OCPM is used by OMHA reconsiderations of Medicare eligibility the OMHA Chief Administrative Law adjudicators and staff to administer the and entitlement, Part B late enrollment Judge establishes the day-to-day OMHA program. It offers day-to-day penalties, and Part B and Part D procedures for carrying out adjudicative operating instructions, policies, and IRMAAs issued by SSA. The review functions, in accordance with procedures based on statutes and process helps ensure requests are applicable statutes, regulations and regulations, and OMHA directives. complete and jurisdictional OMHA directives. The OCPM provides The following is a list and description requirements are met. direction for processing appeals at the of new OCPM provisions and the Dated: June 30, 2015. OMHA level of adjudication for subject matter. For future quarterly Nancy J. Griswold, Medicare Part A and B claims; Part C notices, we will list only the specific Chief Administrative Law Judge, Office of organization determinations; Part D updates to the list of manual provisions Medicare Hearings and Appeals. coverage determinations; and SSA that have occurred in the covered 3- [FR Doc. 2015–16824 Filed 7–9–15; 8:45 am] eligibility and entitlement, Part B late month period. This information is BILLING CODE 4152–01–P enrollment penalty, and IRMAA available on our Web site at http://www. determinations. hhs.gov/omha/OMHA_Case_Processing_ Section 1871(c) of the Act requires Manual/index.html. DEPARTMENT OF HEALTH AND that we publish a list of all Medicare HUMAN SERVICES manual instructions, interpretive rules, OCPM Division I: General Matters statements of policy, and guidelines of Chapter 1, Manual Overview, National Institutes of Health general applicability not issued as Definitions, Governance. This new regulations at least every 3 months in Center for Scientific Review; Notice of chapter provides a general overview of Closed Meeting the Federal Register. the OCPM, including the purpose of the II. Format for the Quarterly Issuance manual, how it is organized and used, Pursuant to section 10(d) of the Notices a list of acronyms and abbreviations Federal Advisory Committee Act, as used in the manual, and how manual amended (5 U.S.C. App.), notice is This quarterly notice announces the provisions will be updated. hereby given of the following meeting. publication of the initial OCPM The meeting will be closed to the chapters. A hyperlink to the available OCPM Division II: Part A/B Claim public in accordance with the chapters on the OMHA Web site is Determinations provisions set forth in sections provided below. The OMHA Web site 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., contains the most current, up-to-date Chapter 3, Procedural Screening. This new chapter describes the review as amended. The grant applications and chapters and revisions to chapters, and the discussions could disclose will be available earlier than we publish process for new requests for hearing on Medicare Part A and Part B confidential trade secrets or commercial our quarterly notice. We believe the property such as patentable material, OMHA Web site list provides more reconsiderations issued by Qualified Independent Contractors (QICs) and and personal information concerning timely access to the current OCPM individuals associated with the grant chapters for those involved in the Quality Improvement Organizations (QIOs), and escalations of requests for applications, the disclosure of which Medicare claim, organization and would constitute a clearly unwarranted coverage determination and entitlement reconsideration by a QIC. The review process helps ensure requests are invasion of personal privacy. appeals processes. We also believe the complete and jurisdictional Name of Committee: Center for Scientific Web site offers the public a more Review Special Emphasis Panel; Member convenient tool for real time access to requirements are met. Conflict: Topics in Steroids Regulation and current OCPM provisions. In addition, OCPM Division III: Part C Organization Disease. OMHA has a listserv to which the Determinations Date: July 9, 2015. public can subscribe to receive Time: 1:30 p.m. to 2:30 p.m. mstockstill on DSK4VPTVN1PROD with NOTICES immediate notification of any updates to Chapter 3, Procedural Screening. This Agenda: To review and evaluate grant the OMHA Web site. This listserv new chapter describes the review applications. avoids the need to check the OMHA process for new requests for hearing on Place: National Institutes of Health, 6701 Rockledge Drive, Bethesda, MD 20892 Web site, as update notifications are Medicare Part C reconsiderations issued (Telephone Conference Call). sent to subscribers as they occur. If by an Independent Review Entity and Contact Person: Elaine Sierra-Rivera, Ph.D., accessing the OMHA Web site proves to QIOs. The review process helps ensure Scientific Review Officer, Genes, Genomes, be difficult, the contact person listed requests are complete and jurisdictional and Genetics IRG, Center for Scientific above can provide the information. requirements are met. Review, National Institutes of Health, 6701 VerDate Sep<11>2014 19:51 Jul 09, 2015 Jkt 235001 PO 00000 Frm 00042 Fmt 4703 Sfmt 4703 E:\FR\FM\10JYN1.SGM 10JYN1


Document Created: 2018-02-23 09:15:18
Document Modified: 2018-02-23 09:15:18
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice.
ContactJason Green, by telephone at (703) 235-0124, or by email at [email protected]
FR Citation80 FR 39785 
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