Notice2022-06326
Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-October Through December 2021
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Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
March 25, 2022
Issuing agencies
Health and Human Services Department
Abstract
This quarterly notice lists the OMHA Case Processing Manual (OCPM) instructions that were published from October through December 2021. 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.
Full Text
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<title>Federal Register, Volume 87 Issue 58 (Friday, March 25, 2022)</title>
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[Federal Register Volume 87, Number 58 (Friday, March 25, 2022)]
[Notices]
[Pages 17093-17095]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-06326]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-2201-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--October Through December 2021
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 October through December
2021. 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: Jon Dorman, by telephone at (571) 457-
7220, or by email at <a href="/cdn-cgi/l/email-protection#472d2829692328352a2629072f2f3469202831"><span class="__cf_email__" data-cfemail="a8c2c7c686ccc7dac5c9c6e8c0c0db86cfc7de">[email protected]</span></a>.
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
[[Page 17094]]
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 (IRE) for Part C organization determination
appeals, or by PDPSs and an IRE 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 October through
December 2021. 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. The OCPM can be accessed at <a href="https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html">https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html</a>.
IV. OCPM Releases for October Through December 2021
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 issued or revised in the three-month period of October through
December 2021. This information is available on our website at <a href="https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html">https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html</a>.
General OCPM Updates
The Code of Federal Regulations (CFR) is the codification of the
general and permanent rules published in the Federal Register by the
executive departments and agencies of the Federal Government. The OCPM
frequently cites to the governing regulations for the Medicare Program
contained in the CFR. The OCPM provides hyperlinks to those regulation
citations at the Electronic Code of Federal Regulations (eCFR) website,
available at <a href="https://www.ecfr.gov">https://www.ecfr.gov</a>.
In late summer 2021, the eCFR website underwent significant
updates. These updates rendered many of the eCFR hyperlinks embedded in
the OCPM inoperable. To reconcile the OCPM with these updates, OMHA
made revisions to footnotes and citations in the following sections:
4.4.1.3, 5.2.1.2, 5.4.1, 5.4.3, 7.1.1.1, 7.1.1.2, 7.1.4.1, 7.2.1,
7.2.2, 7.3.1, 7.3.2, 7.3.4, 7.4.3, 7.5.2, 7.5.4, 7.5.5, 7.5.6, 7.5.8,
7.5.9, 10.5.2, 10.5.3, 10.7.10.1, 10.7.11, 10.7.11.1, 10.7.11.2,
11.3.2, 11.4.5, 17.1.4, 17.1.5.2, 17.1.5.4, 17.1.11.1, 17.2.1, 20.1.4,
20.2.2, 20.4.3.
OCPM Chapter 11: Procedural Review and Determinations--Section 11.3.2
This chapter was initially released on May 24, 2019, and was
included in a quarterly notice published in the July 16, 2019 Federal
Register (84 FR 33956). Section 11.3 of this chapter describes the
amount in controversy (AIC) that is the statutory threshold monetary
amount that a party with standing to appeal must meet to be entitled to
a hearing or review of a dismissal.
CMS issues annual adjustments to the AIC threshold amounts for ALJ
hearings and judicial review under the Medicare appeals process. This
revision to OCPM 11.3.2 updates the table in this section to reflect
the AIC for the ten most recent calendar years.
OCPM Chapter 16: Decisions--Section 16.4.3
This chapter was initially released on October 9, 2019, and was
included in a quarterly notice published in the July 1, 2020 Federal
Register (85 FR 39571). Section 16.4.3 of this chapter describes when
an adjudicator issues a stipulated decision. A stipulated decision may
be issued when CMS, a CMS contractor, or a plan submits a written
statement, or makes an oral statement at a hearing, indicating that an
enrollee's at-risk determination should be reversed, or that the items
or services at issue should be covered or payment may be made, and
agreeing to the amount of payment that the parties believe should be
made, if the amount of payment is at issue. This revision updates
footnote 15 in section 16.4.3 to reflect the revised regulation at 42
CFR 422.562(d)(3) that became effective on March 22, 2021 (86
[[Page 17095]]
FR 6101), which provides that, ``for the sole purpose of applying the
regulations at Sec. 405.1038(c) of this chapter, an MA organization is
included in the definition of ``contractors'' as it relates to
stipulated decisions.''
OCPM Chapter 20: Post-Adjudication Actions--Sections 20.5.3, 20.6.4,
20.7.4, 20.8.4, 20.9.2, 20.11.2
This chapter was initially released on May 25, 2018, and was
included in a quarterly notice published in the August 7, 2018 Federal
Register (83 FR 38700). Since the initial release, the OMHA Central
Operations office relocated. This revision updates the Central
Operations mailing address accordingly in sections 20.5.3, 20.6.4,
20.7.4, 20.8.4, 20.9.2, and 20.11.2.
Karen W. Ames,
Executive Director, Office of Medicare Hearings and Appeals.
[FR Doc. 2022-06326 Filed 3-24-22; 8:45 am]
BILLING CODE 4150-46-P
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