81 FR 8969 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-October Through December 2015
DEPARTMENT OF HEALTH AND HUMAN SERVICES Federal Register Volume 81, Issue 35 (February 23, 2016)
Federal Register Volume 81, Issue 35 (February 23, 2016)
| Page Range | 8969-8970 | |
| FR Document | 2016-03634 |
[Federal Register Volume 81, Number 35 (Tuesday, February 23, 2016)] [Notices] [Pages 8969-8970] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2016-03634] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES [OMHA-1503-N] Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances--October Through December 2015 AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS. ACTION: Notice. ----------------------------------------------------------------------- SUMMARY: This quarterly notice lists of the OMHA Case Processing Manual (OCPM) manual instructions that were published from October through December, 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 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 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 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 [[Page 8970]] reader may determine whether any are of particular interest. We expect this notice to be used in concert with the previously published notices. The OCPM can be accessed at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html. IV. OCPM Releases for October Through December 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 that have been implemented 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 7, Adjudication Time Frames. This new chapter describes the cases subject to statutory time frames, tolling and waivers of adjudication time frames, and provides instruction on how to handle cases escalated from the Qualified Independent Contractor (QIC) to OMHA and from OMHA to the Medicare Appeals Council. OCPM Division II: Part A/B Claim Determinations Chapter 4, Administrative Record. This new chapter describes the minimum organization and exhibiting structure for documents and evidence received in support of Medicare Part A and B requests for hearing filed with OMHA. This chapter standardizes the way that OMHA prepares these files for further processing. Chapter 7, Scheduling and Notices of Hearing. This new chapter describes the scheduling and notice of hearing process in Medicare Part A and Part B cases and provides guidance on sending amended notices of hearing, rescheduling or cancelling hearings and issuing notices for supplemental hearings. Chapter 13, Closing the Case. This new chapter describes the necessary administrative steps to finalize and close a Medicare Part A or Part B case. The chapter also provides guidance on mailing the notice of disposition and shipping the case file. OCPM Division III: Part C Organization Determinations Chapter 4, Administrative Record. This new chapter describes the minimum organization and exhibiting structure for documents and evidence received in support of Medicare Part C requests for hearing filed with OMHA. This chapter standardizes the way that OMHA prepares these files for further processing. Chapter 7, Scheduling and Notices of Hearing. This new chapter describes the scheduling and notice of hearing process in Medicare C cases and provides guidance on sending amended notices of hearing, rescheduling or cancelling hearings and issuing notices for supplemental hearings. Chapter 13, Closing the Case. This new chapter describes the necessary administrative steps to finalize and close a Medicare Part C case. The chapter also provides guidance on mailing the notice of disposition and shipping the case file. OCPM Division IV: Part D Coverage Determinations Chapter 4, Administrative Record. This new chapter describes the minimum organization and exhibiting structure for documents and evidence received in support of Medicare Part D requests for hearing filed with OMHA. This chapter standardizes the way that OMHA prepares these files for further processing. Chapter 7, Scheduling and Notices of Hearing. This new chapter describes the scheduling and notice of hearing process in Medicare D cases and provides guidance on sending amended notices of hearing, rescheduling or cancelling hearings and issuing notices for supplemental hearings. Chapter 13, Closing the Case. This new chapter describes the necessary administrative steps to finalize and close a Medicare Part D case. The chapter also provides guidance on mailing the notice of disposition and shipping the case file. OCPM Division V: SSA Determinations Chapter 4, Administrative Record. This new chapter describes the minimum organization and exhibiting structure for documents and evidence received in support of requests for hearing filed with OMHA following reconsiderations of Medicare eligibility and entitlement, Part B late enrollment penalties, and Part B and Part D IRMAAs issued by SSA. This chapter standardizes the way that OMHA prepares these files for further processing. Chapter 7, Scheduling and Notices of Hearing. This new chapter describes the scheduling and notice of hearing process for requests for hearing filed following reconsideration of Medicare eligibility and entitlement, Part B late enrollment penalties, and Part B and Part D IRMAAs issued by SSA. The chapter also provides guidance on sending amended notices of hearing, rescheduling or cancelling hearings and issuing notices for supplemental hearings. Chapter 13, Closing the Case. This new chapter describes the necessary administrative steps to finalize and close a case on appeal at OMHA following reconsideration of Medicare eligibility and entitlement, Part B late enrollment penalties, and Part B and Part D IRMAAs issued by SSA. The chapter also provides guidance on mailing the notice of disposition and shipping the case file. Dated: February 8, 2016. Jason M. Green, Chief Advisor, Office of Medicare Hearings and Appeals. [FR Doc. 2016-03634 Filed 2-22-16; 8:45 am] BILLING CODE 4152-01-P
![Federal Register / Vol. 81, No. 35 / Tuesday, February 23, 2016 / Notices 8969
FDA will do its best to accommodate 777–2705, or by email at regulations at 42 CFR part 405 subparts
requests to present. FDA urges amanda.axeen@hhs.gov. I and J; part 417, subpart Q; part 422,
individuals and organizations with SUPPLEMENTARY INFORMATION: subpart M; part 423, subparts M and U;
common interests to consolidate or and part 478, subpart B. As noted above,
coordinate their comments, and request I. Background OMHA administers the nationwide
a single time for a joint presentation. For The Office of Medicare Hearings and Administrative Law Judge hearing
those requesters with Internet access, Appeals (OMHA), a staff division within program in accordance with these
Caryn Cohen (see FOR FURTHER the Office of the Secretary of the U.S. statutes and applicable regulations. As
INFORMATION CONTACT) will email you Department of Health and Human part of that effort, OMHA is establishing
regarding your request to speak by Services (HHS), administers the a manual, the OMHA Case Processing
March 1, 2016. nationwide Administrative Law Judge Manual (OCPM). Through the OCPM,
hearing program for Medicare claim, the OMHA Chief Administrative Law
IV. Transcripts organization and coverage Judge establishes the day-to-day
Please be advised that as soon as a determination, and entitlement appeals procedures for carrying out adjudicative
transcript is available, it will be under sections 1869, 1155, functions, in accordance with
accessible at http:// 1876(c)(5)(B), 1852(g)(5), and 1860D– applicable statutes, regulations and
www.regulations.gov. It may be viewed 4(h) of the Social Security Act (the Act). OMHA directives. The OCPM provides
at the Division of Dockets Management OMHA ensures that Medicare direction for processing appeals at the
(HFA–305), Food and Drug beneficiaries and the providers and OMHA level of adjudication for
Administration, 5630 Fishers Lane, Rm. suppliers that furnish items or services Medicare Part A and B claims; Part C
1061, Rockville, MD 20852. A transcript to Medicare beneficiaries, as well as organization determinations; Part D
will also be available in either hardcopy Medicare Advantage Organizations coverage determinations; and SSA
or on CD–ROM, after submission of a (MAOs) and Medicaid State Agencies, eligibility and entitlement, Part B late
Freedom of Information request. The have a fair and impartial forum to enrollment penalty, and IRMAA
Freedom of Information office address is address disagreements with Medicare determinations.
available on the Agency’s Web site at coverage and payment determinations Section 1871(c) of the Act requires
http://www.fda.gov. It will also be made by Medicare contractors, MAOs, that we publish a list of all Medicare
available after the workshop at http:// or Part D Plan Sponsors (PDPSs), and manual instructions, interpretive rules,
www.fda.gov/TobaccoProducts/ determinations related to Medicare statements of policy, and guidelines of
NewsEvents/ucm238308.htm as soon as eligibility and entitlement, Part B late general applicability not issued as
the official transcript is finalized. enrollment penalty, and income-related regulations at least every 3 months in
monthly adjustment amounts (IRMAA) the Federal Register.
Dated: February 18, 2016.
made by the Social Security
Leslie Kux, II. Format for the Quarterly Issuance
Administration (SSA).
Associate Commissioner for Policy. Notices
The Medicare claim, organization and
[FR Doc. 2016–03712 Filed 2–22–16; 8:45 am] coverage determination appeals This quarterly notice provides the
BILLING CODE 4164–01–P processes consist of four levels of specific updates to the OCPM that have
administrative review, and a fifth level occurred in the 3-month period. A
of review with the Federal district hyperlink to the available chapters on
DEPARTMENT OF HEALTH AND courts after administrative remedies the OMHA Web site is provided below.
HUMAN SERVICES under HHS regulations have been The OMHA Web site contains the most
exhausted. The first two levels of review current, up-to-date chapters and
[OMHA–1503–N] are administered by the Centers for revisions to chapters, and will be
Medicare & Medicaid Services (CMS) available earlier than we publish our
Medicare Program; Administrative Law and conducted by Medicare contractors quarterly notice. We believe the OMHA
Judge Hearing Program for Medicare for claim appeals, by MAOs and an Web site list provides more timely
Claim and Entitlement Appeals; independent review entity for Part C access to the current OCPM chapters for
Quarterly Listing of Program organization determination appeals, or those involved in the Medicare claim,
Issuances—October Through by PDPSs and an independent review organization and coverage
December 2015 entity for Part D coverage determination determination and entitlement appeals
appeals. The third level of review is processes. We also believe the Web site
AGENCY: Office of Medicare Hearings administered by OMHA and conducted offers the public a more convenient tool
and Appeals (OMHA), HHS. by Administrative Law Judges. The for real time access to current OCPM
ACTION: Notice. fourth level of review is administered by provisions. In addition, OMHA has a
the HHS Departmental Appeals Board listserv to which the public can
SUMMARY: This quarterly notice lists of (DAB) and conducted by the Medicare subscribe to receive immediate
the OMHA Case Processing Manual Appeals Council. In addition, OMHA notification of any updates to the
(OCPM) manual instructions that were and the DAB administer the second and OMHA Web site. This listserv avoids
published from October through third levels of appeal, respectively, for the need to check the OMHA Web site,
December, 2015. This manual Medicare eligibility, entitlement, Part B as update notifications are sent to
standardizes the day-to-day procedures late enrollment penalty, and IRMAA subscribers as they occur. If accessing
for carrying out adjudicative functions,
mstockstill on DSK4VPTVN1PROD with NOTICES
reconsiderations made by SSA; a fourth the OMHA Web site proves to be
in accordance with applicable statutes, level of review with the Federal district difficult, the contact person listed above
regulations and OMHA directives, and courts is available after administrative can provide the information.
gives OMHA staff direction for remedies within SSA and HHS have
processing appeals at the OMHA level been exhausted. III. How To Use the Notice
of adjudication. Sections 1869, 1155, 1876(c)(5)(B), This notice lists the OCPM chapters
FOR FURTHER INFORMATION CONTACT: 1852(g)(5), and 1860D–4(h) of the Act and subjects published during the
Amanda Axeen, by telephone at (571) are implemented through the quarter covered by the notice so the
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![8970 Federal Register / Vol. 81, No. 35 / Tuesday, February 23, 2016 / Notices
reader may determine whether any are structure for documents and evidence enrollment penalties, and Part B and
of particular interest. We expect this received in support of Medicare Part C Part D IRMAAs issued by SSA. The
notice to be used in concert with the requests for hearing filed with OMHA. chapter also provides guidance on
previously published notices. The This chapter standardizes the way that sending amended notices of hearing,
OCPM can be accessed at http:// OMHA prepares these files for further rescheduling or cancelling hearings and
www.hhs.gov/omha/OMHA_Case_ processing. issuing notices for supplemental
Processing_Manual/index.html. Chapter 7, Scheduling and Notices of hearings.
Hearing. This new chapter describes the Chapter 13, Closing the Case. This
IV. OCPM Releases for October scheduling and notice of hearing new chapter describes the necessary
Through December 2015 process in Medicare C cases and administrative steps to finalize and
The OCPM is used by OMHA provides guidance on sending amended close a case on appeal at OMHA
adjudicators and staff to administer the notices of hearing, rescheduling or following reconsideration of Medicare
OMHA program. It offers day-to-day cancelling hearings and issuing notices eligibility and entitlement, Part B late
operating instructions, policies, and for supplemental hearings. enrollment penalties, and Part B and
procedures based on statutes and Chapter 13, Closing the Case. This Part D IRMAAs issued by SSA. The
regulations, and OMHA directives. new chapter describes the necessary chapter also provides guidance on
The following is a list and description administrative steps to finalize and mailing the notice of disposition and
of new OCPM provisions and the close a Medicare Part C case. The shipping the case file.
subject matter that have been chapter also provides guidance on Dated: February 8, 2016.
implemented in the covered 3-month mailing the notice of disposition and
Jason M. Green,
period. The full text of current OCPM shipping the case file.
provisions is available on our Web site Chief Advisor, Office of Medicare Hearings
OCPM Division IV: Part D Coverage and Appeals.
at http://www.hhs.gov/omha/OMHA_
Determinations [FR Doc. 2016–03634 Filed 2–22–16; 8:45 am]
Case_Processing_Manual/index.html.
Chapter 4, Administrative Record. BILLING CODE 4152–01–P
OCPM Division I: General Matters This new chapter describes the
Chapter 7, Adjudication Time Frames. minimum organization and exhibiting
This new chapter describes the cases structure for documents and evidence DEPARTMENT OF HEALTH AND
subject to statutory time frames, tolling received in support of Medicare Part D HUMAN SERVICES
and waivers of adjudication time requests for hearing filed with OMHA.
National Institutes of Health
frames, and provides instruction on how This chapter standardizes the way that
to handle cases escalated from the OMHA prepares these files for further Center for Scientific Review; Notice of
Qualified Independent Contractor (QIC) processing. Closed Meetings
to OMHA and from OMHA to the Chapter 7, Scheduling and Notices of
Medicare Appeals Council. Hearing. This new chapter describes the Pursuant to section 10(d) of the
scheduling and notice of hearing Federal Advisory Committee Act, as
OCPM Division II: Part A/B Claim process in Medicare D cases and amended (5 U.S.C. App.), notice is
Determinations provides guidance on sending amended hereby given of the following meetings.
Chapter 4, Administrative Record. notices of hearing, rescheduling or The meetings will be closed to the
This new chapter describes the cancelling hearings and issuing notices public in accordance with the
minimum organization and exhibiting for supplemental hearings. provisions set forth in sections
structure for documents and evidence Chapter 13, Closing the Case. This 552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
received in support of Medicare Part A new chapter describes the necessary as amended. The grant applications and
and B requests for hearing filed with administrative steps to finalize and the discussions could disclose
OMHA. This chapter standardizes the close a Medicare Part D case. The confidential trade secrets or commercial
way that OMHA prepares these files for chapter also provides guidance on property such as patentable material,
further processing. mailing the notice of disposition and and personal information concerning
Chapter 7, Scheduling and Notices of shipping the case file. individuals associated with the grant
Hearing. This new chapter describes the applications, the disclosure of which
scheduling and notice of hearing OCPM Division V: SSA Determinations would constitute a clearly unwarranted
process in Medicare Part A and Part B Chapter 4, Administrative Record. invasion of personal privacy.
cases and provides guidance on sending This new chapter describes the Name of Committee: Center for Scientific
amended notices of hearing, minimum organization and exhibiting Review Special Emphasis Panel; Member
rescheduling or cancelling hearings and structure for documents and evidence Conflict: Ethology, Addiction and
issuing notices for supplemental received in support of requests for Development.
hearings. hearing filed with OMHA following Date: March 14, 2016.
Chapter 13, Closing the Case. This reconsiderations of Medicare eligibility Time: 11:00 a.m. to 1:00 p.m.
new chapter describes the necessary and entitlement, Part B late enrollment Agenda: To review and evaluate grant
penalties, and Part B and Part D applications.
administrative steps to finalize and
Place: National Institutes of Health, 6701
close a Medicare Part A or Part B case. IRMAAs issued by SSA. This chapter Rockledge Drive, Bethesda, MD 20892
The chapter also provides guidance on standardizes the way that OMHA (Virtual Meeting).
mstockstill on DSK4VPTVN1PROD with NOTICES
mailing the notice of disposition and prepares these files for further Contact Person: Wind Cowles, Ph.D.,
shipping the case file. processing. Scientific Review Officer, Center for
Chapter 7, Scheduling and Notices of Scientific Review, National Institutes of
OCPM Division III: Part C Organization Hearing. This new chapter describes the Health, 6701 Rockledge Drive Room 3172,
Determinations scheduling and notice of hearing Bethesda, MD 20892, cowleshw@csr.nih.gov.
Chapter 4, Administrative Record. process for requests for hearing filed Name of Committee: Center for Scientific
This new chapter describes the following reconsideration of Medicare Review Special Emphasis Panel; Small
minimum organization and exhibiting eligibility and entitlement, Part B late Business: Cardiovascular Sciences.
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Document Created: 2018-02-02 14:33:38
Document Modified: 2018-02-02 14:33:38
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice. | |
| Contact | Amanda Axeen, by telephone at (571) 777-2705, or by email at [email protected] | |
| FR Citation | 81 FR 8969 |
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