80 FR 73782 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Federal Register Volume 80, Issue 227 (November 25, 2015)

This quarterly notice lists the OMHA Case Processing Manual (OCPM) manual instructions that were published from July through September 2015. 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, Number 227 (Wednesday, November 25, 2015)]
[Notices]
[Pages 73782-73783]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2015-30044]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

[OMHA-1502-N]


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

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) manual instructions that were published from July through 
September 2015. 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: Amanda Axeen, by telephone at (571) 
777-2705, 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 (ALJ) 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 penalties, 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 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 has established 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

[[Page 73783]]

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 provides the specific updates to the OCPM 
that have occurred in the 3-month period. 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 the previously published notice. The OCPM can be accessed 
at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.

IV. OCPM Releases for July Through September 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 and revised OCPM 
provisions, and the subject matter, that have been released in the 
covered 3-month period. The full text of current OCPM provisions is 
available on our Web site at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.

OCPM Division I: General Matters

    Chapter 4, Parties. This new chapter describes who qualify as 
parties to the ALJ hearing and review process under the applicable 
authorities to guide OMHA ALJs and support staff in ensuring those 
filing requests for hearing and requests for review with OMHA have 
standing to pursue appeals, and notices and other correspondence are 
sent to the appropriate individuals and entities in accordance with the 
authorities.
    Chapter 5, Representatives. This new chapter describes the roles 
and responsibilities of party representatives in the ALJ hearing and 
review process, as well as the requirements to substantiate that an 
individual is authorized or appointed to act as a party representative 
under the applicable authorities.
    Chapter 6, CMS and CMS Contractor Roles. This new chapter describes 
the roles and responsibilities of CMS and its contractors in the ALJ 
hearing and review process, including under what conditions and how CMS 
or a contractor may participate in the process, including at oral 
hearings before OMHA ALJs, in accordance with the applicable 
authorities.

OCPM Division II: Part A/B Claim Determinations

    Chapter 3, Procedural Screening. This chapter has been updated to 
correct a typographical error. No substantive changes were made to the 
chapter.

    Dated: _November 17, 2015.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of Medicare Hearings and 
Appeals.
[FR Doc. 2015-30044 Filed 11-24-15; 8:45 am]
BILLING CODE 4152-01-P