83 FR 56859 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES Federal Register Volume 83, Issue 220 (November 14, 2018)
Federal Register Volume 83, Issue 220 (November 14, 2018)
| Page Range | 56859-56860 | |
| FR Document | 2018-24722 |
[Federal Register Volume 83, Number 220 (Wednesday, November 14, 2018)] [Notices] [Pages 56859-56860] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2018-24722] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES [OMHA-1802-N] Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances--July Through September 2018 AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS. ACTION: Notice. ----------------------------------------------------------------------- SUMMARY: This quarterly notice lists the OMHA Case Processing Manual (OCPM) instructions that were published from July through September 2018. 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 (571) 777-2723, 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 for Part C organization determination appeals, or by PDPSs and an independent review entity 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 quarterly notice provides the specific updates to the OCPM that have occurred in the three-month period of July through September 2018. 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 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 https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html. IV. OCPM Releases for July Through September 2018 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 revised in the three-month period of July through September 2018. 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 5: Representatives Chapter 5, Representatives. This chapter describes the role of representatives in the appeals process, including the documentation required [[Page 56860]] to establish a valid representation, representative rights and responsibilities, communications with representatives and represented parties, and changes of representative due to delegation, revocation, or termination of an appointment. This chapter also discusses the fee approval process for representatives and the circumstances under which an eligible individual or entity may be entitled to reasonable attorney fees and other expenses under the Equal Access to Justice Act. OCPM Chapter 6: CMS, CMS Contractor, and Plan Roles Chapter 6, CMS, CMS Contractor, and Plan Roles. This chapter describes when and how CMS, a CMS contractor, or a plan (for example, a Medicare Advantage organization or Part D plan sponsor) may join the proceedings on a request for hearing as a party or as a non-party participant. This chapter also describes the requirements for a valid election or request to participate in the proceedings, and the circumstances under which an election may be deemed invalid or a request may be denied. This chapter also discusses when evidence, position papers, and written testimony may be submitted by CMS, a CMS contractor, or a plan. OCPM Chapter 7: Adjudication Time Frames, Case Prioritization, and Escalations Chapter 7, Adjudication Time Frames, Case Prioritization, and Escalations. This chapter describes the time frames for an adjudicator to issue a decision, dismissal, or remand in an appeal. This chapter also addresses when an adjudication time frame may be delayed or extended, and how it can be waived by the appellant. This chapter discusses OMHA's case prioritization policy, which determines the general order in which appeals are processed. Lastly, this chapter describes the types of appeal that may be escalated to the Medicare Appeals Council when an adjudicator is unable to issue a decision, dismissal, or remand within an applicable adjudication time frame, and the requirements for a valid request for escalation. OCPM Chapter 14: Scheduling and Noticing for Prehearing Conferences and Hearings Chapter 14, Scheduling and Noticing for Prehearing Conferences and Hearings. This chapter describes the process for scheduling and providing notice of prehearing conferences and hearings, the actions that must be completed before a hearing is scheduled, and the circumstances when a hearing is required. This chapter also identifies the parties, potential parties, and participants to whom notices must be sent, and how to address responses to these notices and any objections or requests that may be made by the notice recipients. Finally, this chapter discusses the circumstances in which a hearing may be rescheduled or canceled, and when a supplemental hearing may be necessary. Dated: November 6, 2018. Jason M. Green, Chief Advisor, Office of Medicare Hearings and Appeals. [FR Doc. 2018-24722 Filed 11-13-18; 8:45 am] BILLING CODE 4150-46-P
![Federal Register / Vol. 83, No. 220 / Wednesday, November 14, 2018 / Notices 56859
Dated: November 7, 2018. made by the Social Security and guidelines of general applicability
Leslie Kux, Administration (SSA). not issued as regulations at least every
Associate Commissioner for Policy. The Medicare claim, organization three months in the Federal Register.
[FR Doc. 2018–24763 Filed 11–13–18; 8:45 am] determination, coverage determination,
and at-risk determination appeals II. Format for the Quarterly Issuance
BILLING CODE 4164–01–P
processes consist of four levels of Notices
administrative review, and a fifth level This quarterly notice provides the
DEPARTMENT OF HEALTH AND of review with the Federal district specific updates to the OCPM that have
HUMAN SERVICES courts after administrative remedies occurred in the three-month period of
under HHS regulations have been July through September 2018. A
[OMHA–1802–N] exhausted. The first two levels of review hyperlink to the available chapters on
are administered by the Centers for the OMHA website is provided below.
Medicare Program; Administrative Law Medicare & Medicaid Services (CMS) The OMHA website contains the most
Judge Hearing Program for Medicare and conducted by Medicare contractors current, up-to-date chapters and
Claim and Entitlement Appeals; for claim appeals, by MAOs and an revisions to chapters, and will be
Quarterly Listing of Program independent review entity for Part C available earlier than we publish our
Issuances—July Through September organization determination appeals, or quarterly notice. We believe the OMHA
2018 by PDPSs and an independent review website provides more timely access to
AGENCY: Office of Medicare Hearings entity for Part D coverage determination the current OCPM chapters for those
and Appeals (OMHA), HHS. and at-risk determination appeals. The involved in the Medicare claim;
ACTION: Notice. third level of review is administered by organization, coverage, and at-risk
OMHA and conducted by determination; and entitlement appeals
SUMMARY: This quarterly notice lists the Administrative Law Judges and attorney processes. We also believe the website
OMHA Case Processing Manual (OCPM) adjudicators. The fourth level of review offers the public a more convenient tool
instructions that were published from is administered by the HHS for real time access to current OCPM
July through September 2018. This Departmental Appeals Board (DAB) and provisions. In addition, OMHA has a
manual standardizes the day-to-day conducted by the Medicare Appeals listserv to which the public can
procedures for carrying out adjudicative Council (Council). In addition, OMHA subscribe to receive notification of
functions, in accordance with and the DAB administer the second and certain updates to the OMHA website,
applicable statutes, regulations, and third levels of appeal, respectively, for including when new or revised OCPM
OMHA directives, and gives OMHA Medicare eligibility, entitlement, Part B chapters are posted. If accessing the
staff direction for processing appeals at late enrollment penalty, and IRMAA OMHA website proves to be difficult,
the OMHA level of adjudication. reconsiderations made by SSA; a fourth the contact person listed above can
FOR FURTHER INFORMATION CONTACT: level of review with the Federal district provide the information.
Jason Green, by telephone at (571) 777– courts is available after administrative
remedies within SSA and HHS have III. How To Use the Notice
2723, or by email at jason.green@
hhs.gov. been exhausted. This notice lists the OCPM chapters
Sections 1869, 1155, 1876(c)(5)(B), and subjects published during the
SUPPLEMENTARY INFORMATION: 1852(g)(5), and 1860D–4(h) of the Act quarter covered by the notice so the
I. Background are implemented through the reader may determine whether any are
regulations at 42 CFR part 405 subparts of particular interest. We expect this
The Office of Medicare Hearings and I and J; part 417, subpart Q; part 422, notice to be used in concert with future
Appeals (OMHA), a staff division within subpart M; part 423, subparts M and U; published notices. The OCPM can be
the Office of the Secretary within the and part 478, subpart B. As noted above, accessed at https://www.hhs.gov/about/
U.S. Department of Health and Human OMHA administers the nationwide agencies/omha/the-appeals-process/
Services (HHS), administers the Administrative Law Judge hearing case-processing-manual/index.html.
nationwide Administrative Law Judge program in accordance with these
hearing program for Medicare claim; statutes and applicable regulations. To IV. OCPM Releases for July Through
organization, coverage, and at-risk help ensure nationwide consistency in September 2018
determination; and entitlement appeals that effort, OMHA established a manual, The OCPM is used by OMHA
under sections 1869, 1155, the OCPM. Through the OCPM, the adjudicators and staff to administer the
1876(c)(5)(B), 1852(g)(5), and 1860D– OMHA Chief Administrative Law Judge OMHA program. It offers day-to-day
4(h) of the Social Security Act (the Act). establishes the day-to-day procedures operating instructions, policies, and
OMHA ensures that Medicare for carrying out adjudicative functions, procedures based on statutes and
beneficiaries and the providers and in accordance with applicable statutes, regulations, and OMHA directives.
suppliers that furnish items or services regulations, and OMHA directives. The The following is a list and description
to Medicare beneficiaries, as well as OCPM provides direction for processing of OCPM provisions that were revised in
Medicare Advantage organizations appeals at the OMHA level of the three-month period of July through
(MAOs), Medicaid State agencies, and adjudication for Medicare Part A and B September 2018. This information is
applicable plans, have a fair and claims; Part C organization available on our website at https://
impartial forum to address determinations; Part D coverage www.hhs.gov/about/agencies/omha/the-
disagreements with Medicare coverage determinations and at-risk appeals-process/case-processing-
and payment determinations made by determinations; and SSA eligibility and manual/index.html.
Medicare contractors, MAOs, or Part D entitlement, Part B late enrollment
plan sponsors (PDPSs), and penalty, and IRMAA determinations. OCPM Chapter 5: Representatives
determinations related to Medicare Section 1871(c) of the Act requires Chapter 5, Representatives. This
eligibility and entitlement, Part B late that the Secretary publish a list of all chapter describes the role of
enrollment penalty, and income-related Medicare manual instructions, representatives in the appeals process,
monthly adjustment amounts (IRMAA) interpretive rules, statements of policy, including the documentation required
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![56860 Federal Register / Vol. 83, No. 220 / Wednesday, November 14, 2018 / Notices
to establish a valid representation, a hearing is required. This chapter also Washington, DC 20229–1177,
representative rights and identifies the parties, potential parties, Telephone number (202) 325–0056 or
responsibilities, communications with and participants to whom notices must via email CBP_PRA@cbp.dhs.gov. Please
representatives and represented parties, be sent, and how to address responses note that the contact information
and changes of representative due to to these notices and any objections or provided here is solely for questions
delegation, revocation, or termination of requests that may be made by the notice regarding this notice. Individuals
an appointment. This chapter also recipients. Finally, this chapter seeking information about other CBP
discusses the fee approval process for discusses the circumstances in which a programs should contact the CBP
representatives and the circumstances hearing may be rescheduled or National Customer Service Center at
under which an eligible individual or canceled, and when a supplemental 877–227–5511, (TTY) 1–800–877–8339,
entity may be entitled to reasonable hearing may be necessary. or CBP website at https://www.cbp.
attorney fees and other expenses under Dated: November 6, 2018. gov/.
the Equal Access to Justice Act. Jason M. Green, SUPPLEMENTARY INFORMATION: CBP
OCPM Chapter 6: CMS, CMS Contractor, Chief Advisor, Office of Medicare Hearings invites the general public and other
and Plan Roles and Appeals. Federal agencies to comment on the
[FR Doc. 2018–24722 Filed 11–13–18; 8:45 am] proposed and/or continuing information
Chapter 6, CMS, CMS Contractor, and
Plan Roles. This chapter describes when BILLING CODE 4150–46–P collections pursuant to the Paperwork
and how CMS, a CMS contractor, or a Reduction Act of 1995 (44 U.S.C. 3501
plan (for example, a Medicare et seq.). This proposed information
Advantage organization or Part D plan DEPARTMENT OF HOMELAND collection was previously published in
sponsor) may join the proceedings on a SECURITY the Federal Register (Volume 83 FR
request for hearing as a party or as a Page 35674) on July 27, 2018, allowing
non-party participant. This chapter also U.S. Customs and Border Protection for a 60-day comment period. This
describes the requirements for a valid notice allows for an additional 30 days
[1651–0110]
election or request to participate in the for public comments. This process is
proceedings, and the circumstances Agency Information Collection conducted in accordance with 5 CFR
under which an election may be deemed Activities: Visa Waiver Program Carrier 1320.8. Written comments and
invalid or a request may be denied. This Agreement suggestions from the public and affected
chapter also discusses when evidence, agencies should address one or more of
AGENCY: U.S. Customs and Border the following four points: (1) Whether
position papers, and written testimony Protection (CBP), Department of
may be submitted by CMS, a CMS the proposed collection of information
Homeland Security. is necessary for the proper performance
contractor, or a plan.
ACTION: 30-Day notice and request for of the functions of the agency, including
OCPM Chapter 7: Adjudication Time comments; extension of an existing whether the information will have
Frames, Case Prioritization, and collection of information. practical utility; (2) the accuracy of the
Escalations agency’s estimate of the burden of the
SUMMARY: The Department of Homeland
Chapter 7, Adjudication Time Frames, proposed collection of information,
Security, U.S. Customs and Border
Case Prioritization, and Escalations. including the validity of the
Protection will be submitting the
This chapter describes the time frames methodology and assumptions used; (3)
following information collection request
for an adjudicator to issue a decision, suggestions to enhance the quality,
to the Office of Management and Budget
dismissal, or remand in an appeal. This utility, and clarity of the information to
(OMB) for review and approval in
chapter also addresses when an be collected; and (4) suggestions to
accordance with the Paperwork
adjudication time frame may be delayed minimize the burden of the collection of
Reduction Act of 1995 (PRA). The
or extended, and how it can be waived information on those who are to
information collection is published in
by the appellant. This chapter discusses respond, including through the use of
the Federal Register to obtain comments
OMHA’s case prioritization policy, appropriate automated, electronic,
from the public and affected agencies.
which determines the general order in mechanical, or other technological
Comments are encouraged and will be
which appeals are processed. Lastly, collection techniques or other forms of
accepted (no later than December 14,
this chapter describes the types of information technology, e.g., permitting
2018) to be assured of consideration.
appeal that may be escalated to the electronic submission of responses. The
ADDRESSES: Interested persons are comments that are submitted will be
Medicare Appeals Council when an
invited to submit written comments on summarized and included in the request
adjudicator is unable to issue a decision,
this proposed information collection to for approval. All comments will become
dismissal, or remand within an
the Office of Information and Regulatory a matter of public record.
applicable adjudication time frame, and
Affairs, Office of Management and
the requirements for a valid request for Overview of This Information
Budget. Comments should be addressed
escalation. Collection
to the OMB Desk Officer for Customs
OCPM Chapter 14: Scheduling and and Border Protection, Department of Title: Visa Waiver Program Carrier
Noticing for Prehearing Conferences and Homeland Security, and sent via Agreement.
Hearings electronic mail to dhsdeskofficer@ OMB Number: 1651–0110.
Chapter 14, Scheduling and Noticing omb.eop.gov. Form Number: CBP Form I–775.
for Prehearing Conferences and FOR FURTHER INFORMATION CONTACT: Current Actions: This submission is
Hearings. This chapter describes the Requests for additional PRA information being made to extend the expiration
process for scheduling and providing should be directed to Seth Renkema, date with a decrease in burden hours
notice of prehearing conferences and Chief, Economic Impact Analysis due to updated agency estimates on
hearings, the actions that must be Branch, U.S. Customs and Border respondents. There is no change to
completed before a hearing is Protection, Office of Trade, Regulations information collected or to CBP Form I–
scheduled, and the circumstances when and Rulings, 90 K Street NE, 10th Floor, 775.
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Document Created: 2018-11-14 03:32:13
Document Modified: 2018-11-14 03:32:13
| 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 | Jason Green, by telephone at (571) 777-2723, or by email at [email protected] | |
| FR Citation | 83 FR 56859 |
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