General Notice and Delegation of Authority To Review Decisions Issued by Administrative Law Judges in Certain Medicare Claims; Solicitation of Comments on Existing Procedures for These Appeals

[Federal Register Volume 60, Number 239 (Wednesday, December 13, 1995)]
[Notices]
[Pages 64065-64066]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-30282]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary


General Notice and Delegation of Authority To Review Decisions 
Issued by Administrative Law Judges in Certain Medicare Claims; 
Solicitation of Comments on Existing Procedures for These Appeals

SUMMARY: The publication of this notice and delegation of authority is 
to advise the public that the Department of Health and Human Services' 
Departmental Appeals Board has been given jurisdiction to review the 
decisions of Administrative Law Judges with respect to entitlement to 
coverage and claims for benefits under Medicare Part A, Hospital 
Insurance, and Medicare Part B, Supplementary Medical Insurance. It 
also gives notice of mailing and e-mail addresses to provide 
opportunities for interested parties to make suggestions for 
improvements in the current appeals procedures for these cases.

effective date: October 1, 1995.

for further information contact: Glide B. Morrisson (202) 690-7043, 
(telephone) (202) 690-5863 (FAX).
    Since the inception of the Medicare program, Administrative Law 
Judges (ALJs) from the Social Security Administration (SSA) have 
decided requests for ALJ hearings filed by or on behalf of Medicare 
beneficiaries concerning requests for payment under Part A of Medicare. 
In section 9341 of the Omnibus Budget Reconciliation Act of 1986, Pub. 
L. 99-509, Congress extended similar administrative review rights 
concerning requests for payment under Medicare Part B for services 
furnished on or after January 1, 1987. As a result, SSA's ALJs now 
conduct hearings concerning Medicare claims brought under both Parts A 
and B. Beneficiaries and other parties dissatisfied with an ALJ 
decision on either Part A or Part B claim may request that SSA's 
Appeals Council review the ALJ's decision. The Appeals Council also 
reviews ALJ hearing decisions concerning an individual's entitlement to 
hospital insurance (Part A) and supplementary medical insurance (Part 
B).
    On August 15, 1994, the Social Security Independence and Program 

[[Page 64066]]
    Improvements Act of 1994, Pub. L. 103-296, was enacted, establishing 
SSA as an independent agency. As a result, the Secretary of Health and 
Human Services has decided to delegate to the Chair of the Departmental 
Appeals Board the authority to review ALJ decisions concerning claims 
for payment under Medicare Part A and B as well as ALJ decisions 
concerning entitlement to Medicare coverage. The delegation will be 
effective October 1, 1995. All Medicare cases pending before SSA's 
Appeals Council on September 30, 1995, will thereafter be the 
responsibility of the Departmental Appeals Board (DAB). Request for ALJ 
hearings on claims for payment under Parts A and B and requests for ALJ 
hearings on entitlement to Medicare coverage will continue to be 
decided by the ALJs in SSA's Office of Hearings and Appeals.
    Until the procedures are modified, the DAB will conduct its review 
of ALJ decisions under the existing regulations governing appeals of 
Part A and B claims. Therefore, in conducting its review, the DAB will 
use the procedures provided in the following authorities, as 
applicable: 20 CFR Part 404, Subparts J and R, 42 CFR Part 405, 
Subparts G and H, 42 CFR Part 473, Subpart B (concerning review of 
decisions on Part A and B determinations made by peer review 
organizations) and regulations in 42 CFR part 417 governing review of 
decisions concerning Part A and B claims submitted by enrollees of 
health maintenance organizations, competitive health plans and health 
care prepayment plans. For the cases covered by this delegation, where 
ever the term ``Appeals Council'' is used, the term ``Departmental 
Appeals Board'' should be inserted.
    The DAB, in cooperation with the Health Care Financing 
Administration, will review current procedures for appropriate changes 
and improvements. Interested parties may send comments and suggestions 
to the DAB at the following address: Departmental Appeals Board, 
Department of Health & Human Services, 200 Independence Avenue, S.W., 
Room 637D, Washington, DC 20201, or at the following e-mail address: 
gbm@ospahb.ssw.dhhs.gov.
    On October 13, 1993, I delegated to the Departmental Appeals Board 
my authority to make final decisions on review of, or to decline to 
review, decisions of Administrative Law Judges involving, inter alia, 
provider participation and termination under section 1866(b)(2) of the 
Social Security Act and the other authorities enumerated in that 
delegation. See 58 Fed. Reg. 58171 (October 29, 1993). The delegation 
to the Departmental Appeals Board dated October 13, 1993, superseded 
all previous delegations of authority to review decisions by 
Administrative Law Judges on the referenced authorities, except that 
the delegation provided that the Social Security Administration, Office 
of Hearings and Appeals, Appeals Council continued to have the 
authority to review, or to decline to review, decisions in cases 
pending before it. There are still five of those cases pending; they 
are assigned to the same specialized personnel who are transferring to 
DAB to process the other Medicare appeals being delegated in this 
notice. Thus, notice is hereby given that any case pending before SSA's 
Appeals Council on September 30, 1995 that concerns the authorities 
referenced in the October 13, 1993 delegation will be transferred to 
the Departmental Appeals Board effective October 1, 1995.

Delegation of Authority

    Notice is hereby given that I have delegated to the Chair of the 
Departmental Appeals Board my authority to make final decisions on 
review of, or to decline to review, decisions of Administrative Law 
Judges of the Office of Hearings and Appeals of the Social Security 
Administration involving Title XVIII, Parts A and B of the Social 
Security Act, as provided below:
    1. The authority to make final decisions on review of, or to 
decline to review, decisions of Administrative Law Judges involving 
determinations made under section 1869 of the Social Security Act 
concerning whether an individual is entitled to benefits under Part A 
or Part B, and concerning claims for benefits under Parts A or B.
    2. The authority to make final decisions on review of, or to 
decline to review, decisions of Administrative Law Judges involving 
determinations made under section 1876(c)(5) of the Social Security 
Act, which affect an individual's right to receive items and services, 
without additional cost, from a health maintenance organization.
    3. The authority to make final decisions on review of, or to 
decline to review, decisions of Administrative law Judges involving 
determinations made under section 1155 of the Social Security Act.
    I have also delegated to the Chair of the Departmental Appeals 
Board the authority to make final decisions on review of, or to decline 
to review, decisions of Administrative Law Judges of the Office of 
Hearings and Appeals of the Social Security Administration involving, 
inter alia, provider participation and termination under section 
1866(b)(2) of the Social Security Act and the other authorities 
enumerated in that delegation for any cases pending before SSA's 
Appeals Council on September 30, 1995 that concern the authorities 
referenced in my October 13, 1993 delegation. See 58 Fed. Reg. 58171 
(October 29, 1993).
    These delegations include, but are not limited to, the authority to 
administer oaths and affirmations, to subpoena witnesses and documents, 
to examine witnesses, to exclude or receive and give appropriate weight 
to materials and testimony offered as evidence, and to make findings of 
fact and conclusions of law. These delegations, which supersede all 
previous delegations of authority to make final decisions on review of, 
or to decline to review, decisions by Administrative Law Judges on the 
above-referenced authorities, are effective October 1, 1995. 
Accordingly, all cases decided pursuant to the above-referenced 
authorities that are pending with the Appeals Council of the Office of 
Hearing and Appeals, Social Security Administration on September 30, 
1995, will thereafter be the responsibility of the Chair of the 
Departmental Appeals Board.

    Dated: October 24, 1995.
Donna E. Shalala,
Secretary.
[FR Doc. 95-30282 Filed 12-12-95; 8:45 am]
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