[Federal Register Volume 87, Number 58 (Friday, March 25, 2022)]
[Notices]
[Pages 17093-17095]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[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 https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html.

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 https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html.

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 https://www.ecfr.gov.
    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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