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OMHA Case Processing Manual (OCPM)








  
  
    

  
      



**On this page:** Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | Chapter 7 | Chapter 8 | Chapter 9 | Chapter 10 | Chapter 11 | Chapter 12 | Chapter 13 | Chapter 14 | Chapter 15 | Chapter 16 | Chapter 17 | Chapter 18 | Chapter 19 | Chapter 20



NOTE: OMHA is in the process of drafting new OCPM chapters and revising existing OCPM chapters to reflect changes to the manual’s format and organization. We are also making updates to address changes made by the Medicare appeals final rule that became effective March 20, 2017 (**82 Fed. Reg. 4974 (Jan. 17, 2017)**). You will find new and revised chapters posted here as they become available.



Chapter 1

Chapter Name
			Revision Updates
			Publish DateManual Overview, Definition, and Governance
			Initial Release
			5/25/2018Chapter 2

Chapter Name
			Revision Updates
			Publish DateInformation Disclosure
			Initial Release
			6/17/2020Chapter 2 Information Disclosure material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 3

Adjudicators, Authorities, Burdens, and Standards of Review

Chapter 4

Chapter Name
			Revision Updates
			Publish DateParties - 12092021
			4.4.1.3: Revised to replace inoperative hyperlinks.
			12/9/2021Parties - 07122019
			4.4.1.1: Revised citations to reflect CMS manual update with direct reference to UPICs
			7/12/2019Parties
			Initial Release
			3/29/2019Chapter 4 Parties material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 5

Chapter Name
			Revision Updates
			Publish DateRepresentatives - 12092021
			5.2.1.2, 5.4.1, 5.4.3: Revised to replace inoperative hyperlinks.
			12/9/2021Representatives - 07122019
			5.2.1.2: Revised required elements of an AOR in accordance with revised 42 C.F.R. section 405.910 and updates to chapter 29, section 270.1.2 of the Medicare Claims Processing Manual
			7/12/2019Representatives
			Initial Release
			7/27/2018Chapter 6

Chapter Name
			Revision Updates
			Publish DateCMS, CMS Contractor, and Plan Roles - 07122019
			6.3.4, 6.5.4.1, 6.5.10, 6.7.3.1, 6.7.3.3, 6.7.4: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division; revised to identify recipients for contractor elections, requests, position papers, and written testimony in appeals escalated to OMHA; revised to clarify that an attorney adjudicator may also grant additional time for submissions; revised to clarify that CMS designated the AdQIC to receive notices of hearing
			7/12/2019CMS, CMS Contractor, and Plan Roles - 05242019
			6.3.1.1, 6.3.2: Revised citations to reflect CMS manual update with direct reference to UPICs
			5/24/2019CMS, CMS Contractor, and Plan Roles
			Initial Release
			7/27/2018Chapter 6 CMS, CMS Contractor, and Plan Roles material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 7

Chapter Name
			Revision Updates
			Publish DateAdjudication Time Frames, Case Prioritization, and Escalations - 12092021
			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: Revised to replace inoperative hyperlinks.
			12/9/2021Adjudication Time Frames, Case Prioritization, and Escalations - 07122019
			7.4.4.2: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division
			7/12/2019Adjudication Time Frames, Case Prioritization, and Escalations - 03292019
			7.4.3: Revised case prioritization policy to include inadvertently omitted language
			3/29/2019Adjudication Time Frames, Case Prioritization, and Escalations
			Initial Release
			7/27/2018Chapter 8

Special Case Processing Procedures

Chapter 9

Chapter Name
			Revision Updates
			Publish DateRequest and Correspondence Intake, Docketing, and Assignment - 07122019
			9.3.4, 9.3.6.1: Revised to clarify procedure for assigning OMHA appeal numbers when a single request for hearing identifies more than one reconsideration number; revised footnote citations to reflect relocation of Part D AIC provisions in 42 C.F.R. section 423.1970 to new section 423.2006
			7/12/2019Request and Correspondence Intake, Docketing, and Assignment
			Initial Release
			2/01/2019Chapter 9 Request and Correspondence Intake, Docketing, and Assignment material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 10

Chapter Name
			Revision Updates
			Publish DateParty and Non-Party Participant Requests and Submissions - 12092021
			10.5.2, 10.5.3, 10.7.10.1, 10.7.11, 10.7.11.1, 10.7.11.2: Revised to replace inoperative hyperlinks.
			12/9/2021Party and Non-Party Participant Requests and Submissions
			Initial Release
			2/19/2020Chapter 10 Party and Non-Party Participant Requests and Submissions is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 11

Chapter Name
			Revision Updates
			Publish DateProcedural Review and Determinations - 12092021
			11.3.2, 11.4.5: Revised to update the minimum amount in controversy to reflect the ten most recent calendar years; replace inoperative hyperlinks.
			12/9/2021Procedural Review and Determinations - 07122019
			11.3.4, 11.3.6.3: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division; replace footnote citation to Federal Register with citation to revised 42 C.F.R. section 405.1006(d)(4)
			7/12/2019Procedural Review and Determinations
			Initial Release
			5/24/2019Chapter 11 Procedural Review and Determinations material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 12

Administrative Record and Exhibiting

Chapter Name
			Revision Updates
			Publish DateAdministrative Record and Exhibiting
			Initial Release
			10/28/2022Chapter 12 Administrative Record and Exhibiting material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 13

Issues on Appeal and Case Development

Chapter 14

Chapter Name
			Revision Updates
			Publish DateScheduling and Noticing for Prehearing Conferences and Hearings - 07122019
			14.5.4, 14.6.7.4: Added a footnote clarifying that CMS designated the AdQIC to receive notice of hearing; revised to clarify that the concurrence of the Associate Chief ALJ is only required to grant a request for an in-person hearing
			7/12/2019Scheduling and Noticing for Prehearing Conferences and Hearings
			Initial Release
			9/28/2018Chapter 15

Chapter Name
			Revision Updates
			Publish DateConducting Conferences and Hearings; Posthearing Development
			Initial Release
			11/21/2019Chapter 15 Conducting Conferences and Hearings; Posthearing Development material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 16

Chapter Name
			Revision Updates
			Publish DateDecisions - 12092021
			16.4.3: Revised footnote 15 to reflect the revised regulation at 42 C.F.R. § 422.562(d)(3).
			12/9/2021Decisions
			Initial Release
			10/09/2019Chapter 16 Decisions material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 17

Chapter Name
			Revision Updates
			Publish DateDismissals - 12092021
			17.1.4, 17.1.5.2, 17.1.5.4, 17.1.11.1, 17.2.1: Revised to replace inoperative hyperlinks.
			12/9/2021Dismissals - 07122019
			17.1.5, 17.1.5.3, 17.2.2: Revised footnote citations to reflect relocation of Part D AIC provisions in 42 C.F.R. section 423.1970 to new section 423.2006
			7/12/2019Dismissals
			Initial Release
			11/30/2018Chapter 18

Chapter Name
			Revision Updates
			Publish DateRequests for Information and Remands - 07122019
			18.1.1.2, 18.1.5, 18.1.7.2, 18.2.2, 18.4.3: Revised to clarify that a request for information may be made for an official copy of a dismissal of a request for redetermination or reconsideration, a remand may be issued if the requested information is not provided, and such a remand may be subject to review by the CALJ or designee; revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division
			7/12/2019Requests for Information and Remands
			Initial Release
			11/30/2018Chapter 19

Chapter Name
			Revision Updates
			Publish DateClosing the Case - 03292019
			19.4.3, 19.5.1: Revised to clarify that if an adjudicator issues a consolidated decision, the adjudicator must also consolidate the record and combine the appeals in the case processing system
			3/29/2019Closing the Case
			Initial Release
			5/25/2018Chapter 19 Closing the Case material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.Chapter 20

Chapter Name
			Revision Updates
			Publish DatePost-Adjudication Actions - 09212023 *
			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: Revised to address changes to post-adjudication appeals processing resulting from ECAPE processing, the e-Appeal Portal, and other improvements in appeals operations and processing; revised to remove relatively rare MAS data entry and updating processes; revised to remove secondary approvals for various post-adjudication actions; revised to clarify the distinction between updating the administrative record for ECAPE appeals and non-ECAPE appeals; revised to clarify that if the original adjudicator is not available for more than 20 calendar days, the ACALJ reviews post-adjudication requests and if they decide to grant the request then the appeal is reassigned to the ACALJ; revised to clarify how various post-adjudication requests are filed; revised to update the process to re-establish an appeal; revised to clarify that an adjudicator may not reopen a decision or vacate a dismissal if an appeal is pending with the Council; added new order, Order Denying Review of Request to Vacate a Remand (OMHA-188T), and revised existing order OMHA-189T; revised to clarify that CMS contractor responses to an OMHA remand are not reviewable and appeals are immediately re-established; added new form for Returnable Remand Notice (OMHA-383T); added new section, 20.13, Requests to Obtain Approval of a Fee.
			9/21/2023Post-Adjudication Actions - 12092021
			20.1.4, 20.2.2, 20.4.3, 20.5.3, 20.6.2, 20.6.3.1, 20.6.3.2, 20.6.6.1, 20.6.8, 20.7.1.2, 20.7.1.3, 20.7.1.5, 20.7.2, 20.7.3.1, 20.7.8, 20.8.1.2, 20.8.1.4, 20.8.1.5, 20.8.1.6, 20.8.2, 20.8.3.1, 20.8.3.2, 20.8.3.3, 20.10.4; 20.5.3, 20.6.4, 20.7.4, 20.8.4, 20.9.2, 20.11.2: Revised to replace inoperative hyperlinks; revised to update the OMHA Central Operations mailing address.
			12/9/2021Post-Adjudication Actions - 07122019
			20.5.5.2, 20.7.1.3, 20.7.1.4, 20.7.5.6, 20.7.7.3, 20.8.4, 20.8.5.6, 20.8.6.1, 20.8.7.2, 20.9.1, 20.9.5, 20.10.3, 20.11.4, 20.11.6: Revised to clarify that the re-established appeal number is used on an order vacating a remand; revised to clarify that requests for paper administrative records are made directly with Central Operations; revised to remove an incorrect statement that an ALJ must make a request for information before a remand for a missing case file is authorized under 42 C.F.R. section 405.1056(a)(2); revised time frame for vacating dismissals from 6 months to 180 calendar days in accordance with revised 42 C.F.R. sections 405.1052(e) and 423.2052(e); revised to replace references to OMHA Program Evaluation and Policy Division and Field Operations Division with references to Appeals Policy and Operations Division
			7/12/2019Post-Adjudication Actions
			Initial Release
			5/25/2018*Chapter 20 Post-Adjudication Actions material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

                    
  


Content created by Office of Medicare Hearings and Appeals (OMHA) Content last reviewed September 27, 2023 Back to top
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