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)

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.

[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]


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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.

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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