Notice2023-28625
Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2023
Primary source
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
December 28, 2023
Issuing agencies
Health and Human Services Department
Abstract
This quarterly notice lists the OMHA Case Processing Manual (OCPM) instructions that were published from July through September 2023. 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 88 Issue 248 (Thursday, December 28, 2023)</title>
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[Federal Register Volume 88, Number 248 (Thursday, December 28, 2023)]
[Notices]
[Pages 89710-89711]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-28625]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-2302-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--July Through September 2023
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
2023. 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#81ebeeefafe5eef3ece0efc1e9e9f2afe6eef7"><span class="__cf_email__" data-cfemail="553f3a3b7b313a2738343b153d3d267b323a23">[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 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 July through September
2023. 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
[[Page 89711]]
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 July Through September 2023
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 July through
September 2023. 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>.
OCPM Chapter 20 (Post-Adjudication Actions) Updates
OMHA issued the initial version of this chapter on May 25, 2018,
and included it in a quarterly notice published in the August 7, 2018
Federal Register (83 FR 38700). The revised chapter addresses changes
to post-adjudication appeals processing resulting from increased
electronic case processing through OMHA's Electronic Case Adjudication
and Processing Environment (ECAPE), advances in appeal filing
procedures through the e-Appeal Portal, and other improvements in
appeals operations and processing. This revision removes outdated data
entry processes that were updated with electronic case processing. This
revision also clarifies how post-adjudication actions are processed if
the original adjudicator is not available for more than 20 calendar
days; clarifies how various post-adjudication requests are filed;
updates the operational process to re-establish an appeal. Finally, the
revision adds a new section, 20.13, Requests to Obtain Approval of a
Fee, which incorporates information previously included in OCPM Chapter
5. OMHA made revisions in the following sections: 20.2.1, 20.2.2,
20.3.2, 20.3.4, 20.4.1, 20.4.3, 20.4.4, 20.4.5, 20.4.6, 20.5.2, 20.5.3,
20.5.4, 20.5.5 (multiple), 20.5.7 (multiple), 20.5.8 (multiple), 20.6.1
(multiple), 20.6.2, 20.6.4, 20.6.5 (multiple), 20.6.6.1, 20.6.7
(multiple), 20.7.1.4, 20.7.2, 20.7.4, 20.7.5 (multiple), 20.7.7
(multiple), 20.8.1.3, 20.8.2, 20.8.4, 20.8.5 (multiple), 20.8.6.1,
20.8.7 (multiple), 20.9.1, 20.9.2, 20.9.4, 20.9.5, 20.10.2, 20.10.3,
20.11.2, 20.11.4, 20.11.5, 20.11.6, 20.12.1, 20.12 (multiple), 20.13.
Karen W. Ames,
Executive Director of Operations, Office of Medicare Hearings and
Appeals.
[FR Doc. 2023-28625 Filed 12-27-23; 8:45 am]
BILLING CODE 4150-46-P
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