Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-January Through March 2019, 19086-19088 [2019-09008]
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19086
Federal Register / Vol. 84, No. 86 / Friday, May 3, 2019 / Notices
www.accessdata.fda.gov/scripts/cder/
daf/.
Dated: April 29, 2019.
Lowell J. Schiller,
Principal Associate Commissioner for Policy.
[FR Doc. 2019–09005 Filed 5–2–19; 8:45 am]
BILLING CODE 4164–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Request for Information (RFI):
Developing an STD Federal Action
Plan
Office of HIV/AIDS and
Infectious Disease Policy, Office of the
Assistant Secretary for Health, Office of
the Secretary, Department of Health and
Human Services.
ACTION: Notice.
AGENCY:
To help inform the
development of the Sexually
Transmitted Diseases (STD) Federal
Action Plan, HHS seeks input from
stakeholders on what strategies can be
implemented by federal agencies to
improve the efficiency, effectiveness,
coordination, accountability, and
impact of our national response to
increasing rates of STDs.
DATES: To be assured consideration,
comments must be received at the
address provided below, no later than
5:00 p.m. ET on June 3, 2019.
ADDRESSES: Electronic responses are
strongly preferred and may be addressed
to STDPlan@hhs.gov. Written responses
should be addressed to: U.S.
Department of Health and Human
Services, 330 C Street SW, Room L001,
Washington, DC 20024; Attention STD
RFI.
FOR FURTHER INFORMATION CONTACT:
Melissa Habel, MPH in the HHS Office
of HIV/AIDS and Infectious Disease
Policy, (202) 795–7697.
SUPPLEMENTARY INFORMATION: Rates of
sexually transmitted diseases (STDs) in
2017 reached an all-time high among
males and females and all racial and
ethnic groups. Since 2013, reported
chlamydia rates have increased 22%,
gonorrhea rates 67%, syphilis rates
76%, and congenital syphilis rates
154%; the combined number of cases
was 2.3 million up from 1.8 million in
2013.1 These infections can lead to longterm health consequences such as
infertility and can facilitate HIV
transmission. While gonorrhea,
chlamydia and syphilis infections have
grown considerably over the past four
years, human papillomavirus (HPV)
remains the most commonly sexually
transmitted infection in the U.S.,
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affecting close to half of adults of
reproductive age. HPV infections result
in approximately 33,700 cases of certain
types of cancer each year in the U.S.2
Most of these cancers are preventable
through the use of the HPV vaccination
series. These numbers represent real
people and expose hidden fragile
populations who are not getting the
preventive services and health care they
need. While STDs affect all groups of
the U.S. population, they
disproportionately affect certain
vulnerable groups such as pregnant
women, youth ages 15–24 years, men
who have sex with men, and racial and
ethnic minorities. Beyond the impact on
an individual’s health, in 2013 it was
estimated that STDs cost the U.S. health
care system more than $16 billion
annually, and STDs have increased
dramatically since then.3
To respond and address the STD
public health epidemic, OHAIDP in
collaboration with other federal partners
is leading and coordinating
development of a STD Federal Action
Plan. The development process for the
action plan will seek input from subject
matter experts, nonfederal partners and
stakeholders including health care
providers and systems, state, tribal, and
local health departments, communitybased and faith-based organizations,
national professional organizations,
researchers, advocates, and persons
whose lives have been affected by these
infections. The action plan is expected
to address prevention, diagnosis, care
and treatment, as well as coordination
of efforts, policies, and programs
throughout the federal government. It
will also address stigma, discrimination,
co-infections (e.g., HIV and viral
hepatitis), and social determinants of
health.
This request for information seeks
public input on how the federal
government should address the rising
rates of STDs and what strategies can be
implemented to improve the efficiency,
effectiveness, coordination,
accountability, and impact of the federal
response to STD prevention, care and
treatment policies, services and
programs. The information received will
inform the STD Federal Action Plan.
Topics of interest include but are not
limited to the following:
1. How should the federal government
address the rising rates of STDs?
2. What strategies can be
implemented by federal agencies to
improve the efficiency, effectiveness,
coordination, accountability, and
impact of our national response to
increasing rates of STDs for all priority
populations?
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3. What are the barriers to people
getting the quality STD health services
they deserve? What strategies can be
implemented by federal agencies to
overcome these barriers?
4. How can federal agencies influence,
design and implement STD-related
policies, services and programs in
innovative and culturally-responsive
ways for priority populations?
5. How can the federal government
help to reduce STD-associated stigma
and discrimination?
Dated: April 11, 2019.
Tammy R. Beckham,
Director, Office of HIV/AIDS and Infectious
Disease Policy.
Footnotes
1. Centers for Disease Control and
Prevention. Sexually Transmitted
Disease Surveillance 2017. Atlanta: U.S:
Department of Health and Human
Services, 2018: Available at https://
www.cdc.gov/std/stats.
2. Eng TR, Butler WT, editors; Institute of
Medicine (US). Summary: The hidden
epidemic: Confronting sexually
transmitted diseases. Washington (DC):
National Academy Press; 1997. p. 43.
3. Owusu-Edusei K Jr, Chesson HW, Gift TL,
et al. The estimated direct medical cost
of selected sexually transmitted
infections in the United States, 2008. Sex
Transm Dis 2013; 40(3):197–201.
DOI:10.1097/OLQ.0b013e318285c6d2.
[FR Doc. 2019–09113 Filed 5–2–19; 8:45 am]
BILLING CODE P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[OMHA–1901–N]
Medicare Program; Administrative Law
Judge Hearing Program for Medicare
Claim and Entitlement Appeals;
Quarterly Listing of Program
Issuances—January Through March
2019
Office of Medicare Hearings
and Appeals (OMHA), HHS.
ACTION: Notice.
AGENCY:
This quarterly notice lists the
OMHA Case Processing Manual (OCPM)
instructions that were published from
January through March 2019. 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:
Jason Green, by telephone at (571) 777–
2723, or by email at jason.green@
hhs.gov.
SUMMARY:
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Federal Register / Vol. 84, No. 86 / Friday, May 3, 2019 / Notices
SUPPLEMENTARY INFORMATION:
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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.
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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
January through March 2019. 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.
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19087
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/.
IV. OCPM Releases for January
Through March 2019
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
January through March 2019. This
information is available on our website
at https://www.hhs.gov/about/agencies/
omha/the-appeals-process/caseprocessing-manual/.
OCPM Chapter 4: Parties
The parties to an OMHA appeal are
specified by regulation and vary based
on the matter presented and the
Medicare Part under which the appeal
arises. This newly issued chapter
identifies: (1) The different parties and
potential parties to an appeal; (2) when
an individual or entity may enter the
proceedings as a substitute party; (3)
when and how a beneficiary’s appeal
rights may be assigned to a provider or
supplier; and (4) the procedures OMHA
follows when an appellant’s party status
is unclear. There may be multiple
parties to an appeal, and an individual’s
or entity’s party status is generally not
determined by the individual’s or
entity’s financial interest in the outcome
of the appeal, unless otherwise noted in
this chapter.
OCPM Chapter 7: Adjudication Time
Frames, Case Prioritization, and
Escalations—Section 7.4.3
This chapter was initially released on
July 27, 2018, and was included in a
quarterly notice published in the
November 14, 2018 Federal Register (83
FR 56859). After the initial publication,
we discovered that certain language
from OMHA’s existing case
prioritization policy had been
inadvertently omitted when the policy
was transferred to the OCPM. This
revision to OCPM 7.4.3 corrects this
error by clarifying that, if a beneficiary
is represented by another party or by the
same representative as another party,
OMHA treats the beneficiary’s case as a
Priority 3 appeal (see OCPM 7.4.2),
unless: (1) The beneficiary is or would
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Federal Register / Vol. 84, No. 86 / Friday, May 3, 2019 / Notices
be liable for the costs (other than
deductibles and coinsurance) of the
items or services in dispute; (2) the case
involves a pre-service request for
coverage; or (3) one of the exceptions in
OCPM 7.4.4 applies. The error we
corrected was purely administrative,
and had no effect on the manner in
which OMHA prioritizes appeals.
OCPM Chapter 9: Request and
Correspondence Intake, Docketing, and
Assignment
A number of actions may initiate (or
reinitiate) proceedings at the OMHA
level. This newly issued chapter
provides information on where to direct
appeal requests and submissions, and
details the processes for docketing,
acknowledging, and assigning cases.
This chapter also explains when claims
may be added or removed from an
appeal and how to combine appeals.
While this chapter deals primarily with
processing appeals as paper files, it also
includes guidelines for processing
electronic case files in OMHA’s
Electronic Case Adjudication Processing
Environment (ECAPE).
OCPM Chapter 19: Closing the Case—
Sections 19.4.3, 19.5.1
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).
This revision to OCPM 19.4.3 clarifies
that, in accordance with 42 CFR
405.1044(b) and 423.2044(b), if an
adjudicator issues a consolidated
decision, the adjudicator must also
consolidate the administrative record
and combine the appeals in the case
processing system. OCPM 19.5.1 was
also revised, to clarify that, when an
appeal involves multiple beneficiaries,
any copies of disposition documents
(for example, a decision and any
accompanying notices or enclosures),
must be redacted to display only
personally identifiable information (PII)
that the recipient is entitled to receive.
Dated: April 25, 2019.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings
and Appeals.
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Indian Health Service
Request for Public Comment: 60 Day
Information Collection: Indian Health
Service Forms To Implement the
Privacy Rule
Indian Health Service, HHS.
Notice and request for
comments. Request for extension of
approval.
AGENCY:
ACTION:
In compliance with the
Paperwork Reduction Act of 1995, the
Indian Health Service (IHS) invites the
general public to comment on the
information collection titled, ‘‘IHS
Forms to Implement the Privacy Rule’’
Office of Management and Budget
(OMB) Control Number 0917–0030.
This previously approved information
collection project was last published in
the Federal Register (81 FR 15347) on
March 22, 2016, and allowed 30 days for
public comment. No public comment
was received in response to the notice.
This notice announces our intent to
submit the collection, which expires
August 31, 2019, to OMB for approval
of an extension, and to solicit comments
on specific aspects of the information
collection. A copy of the supporting
statement is available at
www.regulations.gov (see Docket ID
IHS–2016–1).
Title of Collection: 0917–0030, IHS
Forms to Implement the Privacy Rule
(45 CFR parts 160 & 164). Type of
Information Collection Request:
Extension of the currently approved
information collection, 0917–0030, IHS
Forms to Implement the Privacy Rule
(45 CFR parts 160 & 164). Form(s): IHS–
810, IHS–912–1, IHS–912–2, IHS–913,
and IHS–917. Need and Use of
Information Collection: This collection
of information is made necessary by the
Department of Health and Human
Services Rule entitled ‘‘Standards for
Privacy of Individually Identifiable
Health Information’’ (Privacy Rule) (45
CFR parts 160 and 164). The Privacy
Rule implements the privacy
requirements of the Administrative
Simplification subtitle of the Health
Insurance Portability and
Accountability Act of 1996, creates
national standards to protect
individual’s personal health
information, and gives patients
increased access to their medical
records. 45 CFR 164.508, 164.522,
164.526 and 164.528 of the Rule require
the collection of information to
implement these protection standards
and access requirements. The IHS will
SUMMARY:
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continue to use the following data
collection instruments to meet the
information collection requirements
contained in the Rule.
45 CFR 164.508: This provision
generally requires covered entities to
obtain or receive a valid authorization
for its use or disclosure of protected
health information, unless otherwise
permitted or required by the Privacy
Rule. (See, e.g., 45 CFR 164.506 for a
common exception to this general rule,
which involves uses and disclosure for
treatment, payment, or healthcare
operations.) Individuals may initiate a
written authorization permitting
covered entities to release their
protected health information to entities
of their choosing. The form IHS–810
‘‘Authorization for Use or Disclosure of
Protected Health Information’’ is used to
document an individual’s authorization
to use or disclose their protected health
information.
45 CFR 164.522: Section 164.522(a)(1)
requires a covered entity to permit
individuals to request that the covered
entity restrict the use and disclosure of
their protected health information. The
covered entity may or may not agree to
the restriction, and with a limited
exception, a covered entity is not
required to agree to a requested
restriction. 45 CFR 164.522(a)(1)(vi).
The form IHS–912–1 ‘‘Request for
Restrictions(s)’’ is used to document an
individual’s request for restriction of
their protected health information, and
whether the IHS agreed or disagreed
with the restriction. Section
164.522(a)(2) permits a covered entity to
terminate its agreement to a restriction
under certain conditions. For example,
termination may occur if the individual
agrees to or requests the termination in
writing. 45 CFR 164.522(a)(2)(i). The
form IHS–912–2 ‘‘Request for
Revocation of Restriction(s)’’ is used to
document the individual’s request, the
individual’s agreement, and/or the
agency’s decision to terminate a
formerly agreed to restriction regarding
the use and disclosure of protected
health information.
45 CFR 164.528: This provision
requires covered entities to provide an
accounting of certain disclosures of
protected health information made by
the covered entity. See also, 45 CFR
5b.9(c). The form IHS–913 ‘‘Request for
an Accounting of Disclosures’’ is used to
document an individual’s request for an
accounting of disclosures of their
protected health information and the
agency’s handling of the request.
45 CFR 164.526: Under this provision,
individuals have a right to amend
protected health information or a record
about the individual in a designated
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]]>Agencies
[Federal Register Volume 84, Number 86 (Friday, May 3, 2019)]
[Notices]
[Pages 19086-19088]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-09008]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1901-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--January Through March 2019
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This quarterly notice lists the OMHA Case Processing Manual
(OCPM) instructions that were published from January through March
2019. 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: Jason Green, by telephone at (571)
777-2723, or by email at [email protected].
[[Page 19087]]
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 January through March
2019. 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/.
IV. OCPM Releases for January Through March 2019
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 January through
March 2019. This information is available on our website at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/.
OCPM Chapter 4: Parties
The parties to an OMHA appeal are specified by regulation and vary
based on the matter presented and the Medicare Part under which the
appeal arises. This newly issued chapter identifies: (1) The different
parties and potential parties to an appeal; (2) when an individual or
entity may enter the proceedings as a substitute party; (3) when and
how a beneficiary's appeal rights may be assigned to a provider or
supplier; and (4) the procedures OMHA follows when an appellant's party
status is unclear. There may be multiple parties to an appeal, and an
individual's or entity's party status is generally not determined by
the individual's or entity's financial interest in the outcome of the
appeal, unless otherwise noted in this chapter.
OCPM Chapter 7: Adjudication Time Frames, Case Prioritization, and
Escalations--Section 7.4.3
This chapter was initially released on July 27, 2018, and was
included in a quarterly notice published in the November 14, 2018
Federal Register (83 FR 56859). After the initial publication, we
discovered that certain language from OMHA's existing case
prioritization policy had been inadvertently omitted when the policy
was transferred to the OCPM. This revision to OCPM 7.4.3 corrects this
error by clarifying that, if a beneficiary is represented by another
party or by the same representative as another party, OMHA treats the
beneficiary's case as a Priority 3 appeal (see OCPM 7.4.2), unless: (1)
The beneficiary is or would
[[Page 19088]]
be liable for the costs (other than deductibles and coinsurance) of the
items or services in dispute; (2) the case involves a pre-service
request for coverage; or (3) one of the exceptions in OCPM 7.4.4
applies. The error we corrected was purely administrative, and had no
effect on the manner in which OMHA prioritizes appeals.
OCPM Chapter 9: Request and Correspondence Intake, Docketing, and
Assignment
A number of actions may initiate (or reinitiate) proceedings at the
OMHA level. This newly issued chapter provides information on where to
direct appeal requests and submissions, and details the processes for
docketing, acknowledging, and assigning cases. This chapter also
explains when claims may be added or removed from an appeal and how to
combine appeals. While this chapter deals primarily with processing
appeals as paper files, it also includes guidelines for processing
electronic case files in OMHA's Electronic Case Adjudication Processing
Environment (ECAPE).
OCPM Chapter 19: Closing the Case--Sections 19.4.3, 19.5.1
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). This revision to OCPM 19.4.3 clarifies that, in
accordance with 42 CFR 405.1044(b) and 423.2044(b), if an adjudicator
issues a consolidated decision, the adjudicator must also consolidate
the administrative record and combine the appeals in the case
processing system. OCPM 19.5.1 was also revised, to clarify that, when
an appeal involves multiple beneficiaries, any copies of disposition
documents (for example, a decision and any accompanying notices or
enclosures), must be redacted to display only personally identifiable
information (PII) that the recipient is entitled to receive.
Dated: April 25, 2019.
Jason M. Green,
Chief Advisor, Office of Medicare Hearings and Appeals.
[FR Doc. 2019-09008 Filed 5-2-19; 8:45 am]
BILLING CODE 4150-46-P
