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)

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.

[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]


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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.

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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