(Medicare Claims Processing Manual)

https://www.hhs.gov/sites/default/files/OMHA -100A -Multiple -Claim-Attachment.pdf    The link to OMHAs webpage containing all forms:    https://www.hhs.gov/about/agencies/omha/filing- an-appeal/forms/index.html   To request that OMHA make a decision  without a hearing based only on the information thats in the appeal record, an appellant must submit the information required for an ALJ hearing request and one of these:    The Waiver of Right to an Administrative Law Judge (ALJ) Hearing form (Form OMHA -104) available at https://www.hhs.gov/sites/default/files/OMHA -104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf ; or   A written request stating that you dont wish to appear before an ALJ at a hearing (including a hearing held by phone or video- teleconference), and explaining why you decided to waive the hearing.   Even if a waiver of hearing is requested, a hearing may still be held by an ALJ if the other parties in the case dont also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide the case.       330.2 - Forwarding Requests to OMHA  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19) Requests for ALJ hearings are to be  filed with the  OMHA office at the address sp ecified in the  QICs reconside ration noti ce.  How ever, ther e may be times when par ties incorrectly file requests for hearings with e ither the MAC  or QIC.  When a MAC  receives such a misfiled request, it f orwards the  misfiled request to the  OMHA Ce ntral Do cketing lo cation within 30 calendar days of receipt.  All MACs sh all ma intain a reco rd of these cases.  Requests for all A LJ hearings must be  filed at the  follo wing loc ation:    OMHA Centraliz ed Do cketing 200 Public  Squar e, Suite  1260 Cleveland, OH 44114- 2316  330.3 - Review and Effectu ation of OMHA  Decisions (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The Administrative  QIC (AdQI C) is the  clearingh ouse for all Original Me dicare (Part A and Part B)  claim c ase fil es and decisions from the  OMHA fi eld offi ces as w ell as any  decisions and c ase fil es from the  Appe als Counc il.  T he AdQI C reviews OMHA dec isions for  possible  agency r eferral to the  App eals C ounc il.  For Appe als C ounc il decisions and for OMHA  decisions w hen no age ncy referral is plann ed, the  AdQI C will send the  MAC an e ffectuat ion notice, a c opy of the  decision, and a sum mary of the  asso ciated claims from the  MAS.  The MAC only e ffectuates bas ed on doc umentation r eceived from the  AdQI C; the MAC does not e ffectuate  based on c orrespon dence from a ny party  to the  ALJ hearing or attorney adjudicator review.  " Effectuat e" means for t he MAC to issue  a paym ent or change liability.   In the  event that the  MACs c laims pa yment review finds the  OMHA or Appe als C ounc il decision to be  inconsist ent or ina ccurate in c omparison to c laims history  the MAC may r equest assistan ce from the  AdQ IC in seeking c larifi cation from OMHA  or the Appeals C ounc il.  330.4 - Effectuation Time Limits & Responsibilities (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06 -13-19)    In most c ases, OMHA will:  ( 1) issue  a decision ba sed on the  request for an ALJ hearing or review ; or ( 2) issue  an order of dismissal of the appellants request for ALJ hearing or review ; or (3) remand the  case to the  QIC.  If OMHAs  decision is partially  or w holly fa vorable  to the  appellant and gi ves a sp ecific  amount to be  paid, the  MAC e ffectuat es within 30 c alendar da ys of re ceipt of the  effectuation notice from the  AdQI C.  The MAC must a cknowledge receipt of the  AdQIC effectuation pe r the JOA with the  AdQ IC.  If the decision is partiall y or w holly fa vorable  but the  amount must be  computed by the MAC, it e ffectuat es the decision w ithin 30 da ys aft er it comput es the amount to be  paid to the appellant.  T he amount must be  comput ed as s oon as possibl e, but no la ter than w ithin 30 calendar da ys of the  date of receipt of the  effectuation noti ce from the  AdQI C.  For e ffectuation of decisions that in volve overpayments or unde rpayments where the limitation on r ecoupm ent provision  appli es (Section 935 of MMA ), refer to I OM Pub. 100-06, C hapter 3, 200 for furthe r instru ction.  If clarification from the  AdQIC is necessary, the MAC  consider s the date of the clarification the final determination f or purposes of effectuation.  If clarification is n eeded from the provider /physician/suppli er (e.g., splitting c harges), the MAC  requests clarification a s soon a s possible  and comput es the amount pa yable within 30 calendar days after the receipt of  the necessa ry clarification.  The MAC  conside rs the date of receipt of  the clarification a s the d ate of the final determination f or purposes of effectuation.  330.5 - Duplicate OMHA  Decisions  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If the MAC  becom es aware of a dupli cate decision from OMHA on the  same case, it must bring this to the  attention of  the AdQIC imme diately.  In these cases the AdQIC will ta ke the necessa ry steps to re solve  the issue.  330.6 - Payment of Interest on OMHA  Decision s (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  For guidance on how to make payment of interest subsequent to a  decision from OMHA, ref er to chapter 3 of  the Medicare Financial Management M anual, Pub. 100- 06 (http://www.c ms.gov/ma nuals/dow nloads/ fin106c 03.pdf ).    340 - Departmental Appeals Board - Appeals Council - The Fourth L evel of Appeal (Rev. 4278., Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The level of administra tive review available to parties after the ALJ hearing decision, OMHA attorney adjudicator review, or  dismiss al order has been issu ed, bu t before judicial review is available, is App eals Counc il review.  A party  to an  ALJ hearing or an OMHA attorney adjudicator review, may request review by the App eals C ounc il within 60 da ys aft er receipt of the  notice of OMHA s decision or dismissal.  If a party requests the  App eals Counc il to re view an ALJs or attorney adjudicators decision, the  App eals C ouncil may c onduc t a de no vo review of the decision a nd may a dopt, modi fy, or reverse the ALJs or attorney adjudicators d ecision, or  remand the  case  to an ALJ or attorney adjudicator  for further proceedings.  See , in g eneral 42 C FR 405.1108.  The Appeals C ounc il will dismiss a r equest for rev iew when a party  does not ha ve a right to Appeals C ounc il review.  When a party requests th at the App eals C ounc il review an ALJs or attorney adjudicator's dismiss al, the App eals C ounc il ma y deny review or remand the  case  to an ALJ or attorney adjudicator f or further proceedings.  The App eals Counc il may  also dismiss a r equest for a hearing for any r eason the  ALJ or attorney adjudicator c ould ha ve dismiss ed the r equest for hearing.  In addition, the  App eals C ounc il will d ecide cases that are escalated from the  OMHA level without a n ALJ or attorney adjudicator decision or  dismiss al.  See 42 CFR 405.1108(d) .  The Appe als C ounc il may  also d ecide  on its ow n motion to r eview a decision or dismissal issu ed by an A LJ or attorney adjudicator w ithin 60 da ys aft er the date of the decisi on or dismissal.   340.1 - Recommending Agency Referral of OMHA Decisions or Dismissals  (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  CMS may  refer a case to the App eals C ounc il for it to c onside r unde r its o wn motion r eview authority w ithin 60 da ys after the date of the  ALJ hearing or attorney adjudicator decision or dismissal.  T his is know n as an agency referral.  The Appeals C ounc il may  adopt, modif y, or reverse  OMHA s decision, may r emand the  case to an A LJ or attorney adjudicator  for furth er pro ceedings, or may dismiss an ag ency referral re quest.  For OMHA  decisions issu ed by O MHA AL Js and attorney adjudicators, the AdQI C will be  responsible  for rev iewing A LJ and attorney adjudicator decisions and de termining w hether an ag ency referral is appropriat e.  During the effectuation of an A LJ or attorney adjudicator decision, if the  MACs m edical director disagr ees w ith the d ecision and w ishes to dis cuss the  decision for pot ential r eferral to the App eals C ounc il, the me dical dir ector shall c ontact the AdQI C.  340.2 - Effectuation of Appeals Council Orders and Decisions  (Rev. 985, Issued:  06 -16-06; Effective/Implementation Dates:  07 -17-06)    When a MAC receives an effectuation notice from the AdQIC  regarding an Appeals Council decision that requires effectuation, it initiates effectuation within 30 days of its receipt of the effectuation notice, and completes effectuation within 60 days.  Any questions regarding effectuation should be directed to the AdQIC for guidance.   340.3 - Requests for Case Files         (Rev. 4278, Issued: 04 -12-19, Effective: 06- 13-19, Implementation: 06- 13-19)          When the Appeals Council receives a request for review from an appellant, in most          instances it will not have a copy of OMHAs decision or dismissal, or the case file.  The Appeals Council will request all case files from the AdQIC.   340.4 - Payment of Interest on Appeals Council Decisions  (Rev. 985, Issued:  06- 16-06; Effective/Implementation Dates:  07 -17-06)  For guidance on how to make payment of interest subsequent to an Appeals Council decision, refer to chapter 3, of the Medicare Financial Management Manual, Pub. 100- 06.    345 - U.S. District Court Review - The Fifth Level of Appeal  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)