Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2019, 510-512 [2019-28504]
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Federal Register / Vol. 85, No. 3 / Monday, January 6, 2020 / Notices
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Health Resources and Services
Administration
Statement of Organization, Functions
and Delegations of Authority
This notice amends Part R of the
Statement of Organization, Functions
and Delegations of Authority of the
Department of Health and Human
Services (HHS), Health Resources and
Services Administration (HRSA) (60 FR
56605, as amended November 6, 1995;
as last amended at 84 FR 49535–49540
dated September 20, 2019).
HRSA is making changes within their
Healthcare Systems Bureau, Division of
National Hansen’s Program, to improve
the delivery of patient services, increase
management and administrative
efficiencies, and optimize use of staff
resources within the Division.
Specifically this reorganization
updates the functions of the Division of
National Hansen’s Disease Program
(RRH).
Chapter RRH—Division of National
Hansen’s Disease Program
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Section RRH.20 Function
Delete the functional statement for the
Division of National Hansen’s Disease
Program (RRH) in its entirety and
replace with the following:
Division of National Hansen’s Disease
Program (RRH)
The National Hansen’s Disease
Program (NHDP) in accordance with
regulations and the Public Health
Service (PHS) Act, Sec. 320 as amended
by Public Law 105–78, Sec. 211, (1)
provides care and treatment for persons
with Hansen’s Disease (leprosy),
including managing a national shortterm and outpatient health care delivery
program providing specialized services
to persons with Hansen’s Disease; (2)
conducts and promotes the coordination
of research (including clinical research),
investigations, demonstrations, and
studies relating to the causes, diagnosis,
treatment, control, and prevention of
Hansen’s disease and other
mycobacterial diseases and
complications related to such diseases;
(3) conducts training in the diagnosis
and management of Hansen’s disease
and related complications; (4) provides
education and training to staff from the
outpatient Hansen’s Disease Clinics and
to private physicians; (5) operates and
oversees the National Hansen’s Disease
Museum and Cemetery; (6) consults on
the coordination of activities within
HRSA and HHS, and with other federal
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17:53 Jan 03, 2020
Jkt 250001
agencies, state and local governments,
and other public and private
organizations involved in Hansen’s
Disease activities; (7) manages a
network of contracted outpatient clinics
providing care to persons with Hansen’s
Disease; and (8) manages and
coordinates the National Hansen’s
Disease Program’s administrative and
operational activities with HRSA and
HHS, other federal agencies, state and
local governments, and other public and
private organizations involved in
Hansen’s Disease activities.
Section RRH.30, Delegation of Authority
All delegations of authority and redelegations of authority made to
officials and employees of affected
organizational components will
continue in them or their successors
pending further redelegation, if allowed,
provided they are consistent with this
reorganization.
This reorganization is effective upon
date of signature.
(Authority: 44 U.S.C. 3101)
Dated: December 18, 2019.
Thomas J. Engels,
Administrator.
[FR Doc. 2019–28267 Filed 1–3–20; 8:45 am]
BILLING CODE 4165–15–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[OMHA–1903–N]
Medicare Program; Administrative Law
Judge Hearing Program for Medicare
Claim and Entitlement Appeals;
Quarterly Listing of Program
Issuances—July Through September
2019
Office of Medicare Hearings
and Appeals (OMHA), HHS.
AGENCY:
ACTION:
Notice.
This quarterly notice lists the
OMHA Case Processing Manual (OCPM)
instructions that were published from
July through September 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.
SUMMARY:
FOR FURTHER INFORMATION CONTACT:
Dorman, by telephone at (571) 457–
7220, or by email at jon.dorman@
hhs.gov.
SUPPLEMENTARY INFORMATION:
PO 00000
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Jon
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
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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 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
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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 July Through
September 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
July through September 2019. This
information is available on our website
at https://www.hhs.gov/about/agencies/
omha/the-appeals-process/caseprocessing-manual/.
General OCPM Updates
OMHA reorganized its Program
Evaluation and Policy Division and
Field Operations Division into two
branches of a new Appeals Policy and
Operations Division. References to the
prior division names in OCPM chapters
6, 7, 11, 18, and 20 were updated to
reflect the change in OMHA’s
organizational structure.
CMS’s final rule entitled ‘‘Medicare
Program; Changes to the Medicare
Claims and Medicare Prescription Drug
Coverage Determination Appeals
Procedures’’ was published in the May
7, 2019 Federal Register (84 FR 19855)
with an effective date of July 8, 2019.
This final rule made a number of
changes to help streamline the appeals
process and reduce administrative
burden, and to help ensure the
regulations are clearly arranged and
written to give stakeholders a better
understanding of the appeals process.
Among other things, these regulations
corrected and clarified cross references,
definitions, and terminology. To
implement these changes, revisions
were made to footnotes and citations in
OCPM 9.3.6.1, 11.3.6.3, 17.1.5, 17.1.5.3
and 17.2.2.
OCPM Chapter 4: Parties—Section
4.4.1.1
This chapter was initially released on
March 29, 2019, and was included in a
quarterly notice published in the May 3,
2019 Federal Register (84 FR 19086).
Section 4.4.1.1 of this chapter states that
a Unified Program Integrity Contractor
(UPIC) cannot elect party status in an
appeal, and may only participate as a
non-party. As initially published, this
section cited to CMS’s Medicare
Program Integrity Manual (MPIM),
internet-only manual publication 100–
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511
08, chapter 4, section 4.8.2, which
previously stated that a Zone Program
Integrity Contractor (ZPIC) could not
elect party status in an appeal, and
section 4.1, which stated that all
references to ZPICs shall also apply to
UPICs, unless otherwise specified in the
UPIC Statement of Work (SOW).
Effective October 22, 2018, CMS revised
the MPIM to directly state that a UPIC
cannot invoke party status, and can only
participate in OMHA proceedings as a
non-party. This revision to OCPM
4.4.1.1 updates a footnote in this section
to reflect the CMS manual’s revised
language. This revision does not change
the way that OMHA interprets or
implements the underlying policy that a
UPIC cannot elect party status.
OCPM Chapter 5: Representatives—
Section 5.2.1.2
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). Section 5.2.1.2 of this
chapter lists the required elements for a
valid appointment of representative.
This revision updates the required
elements in accordance with revisions
to 42 CFR 405.910(c) that became
effective on July 8, 2019 (84 FR 19857
through 19858), and corresponding
updates to CMS’s Medicare Claims
Processing Manual (MCPM), internetonly manual publication 100–04,
chapter 29, section 270.1.2.
OCPM Chapter 6: CMS, CMS Contractor,
and Plan Roles—Sections 6.5.3.1,
6.5.4.1, 6.5.10, 6.7.3.1, 6.7.3.3, 6.7.4
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). Section 6.5.3.1 of this
chapter previously stated that in a Part
A, Part B, or Part C appeal, CMS or a
CMS contractor may elect to be a party
or non-party participant no later than 10
calendar days after ‘‘receiving the notice
of hearing.’’ This revision implements
changes to 42 CFR 405.1010(b)(3)(ii) and
405.1012(a)(1) (84 FR 19862), and
clarifies that the notice of hearing may
be received by the Qualified
Independent Contractor (QIC) or another
contractor designated by CMS to receive
the notice of hearing. Section 6.5.4.1 of
this chapter is revised to clarify that
CMS has designated the Administrative
Qualified Independent Contractor
(AdQIC) to receive notices of hearing.
Sections 6.5.10 and 6.7.4 of this chapter
previously stated written CMS or
contractor elections and requests and
evidentiary submissions must be sent to
the parties who were sent a copy of the
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Federal Register / Vol. 85, No. 3 / Monday, January 6, 2020 / Notices
reconsideration, if no hearing has been
scheduled; or the parties who were sent
a copy of the notice of hearing, if a
hearing has been scheduled. This
revision implements changes to 42 CFR
405.1010(b)(1) (84 FR19862), and
identifies the copy requirement for
appeals where an appeal has been
escalated to OMHA, but has not been
scheduled. Sections 6.7.3.1 and 6.7.3.3
of this chapter are revised to clarify that
an attorney adjudicator may also grant
additional time for submissions.
OCPM Chapter 9: Request and
Correspondence Intake, Docketing, and
Assignment—Section 9.3.4
This chapter was initially released on
February 1, 2019, and was included in
a quarterly notice published in the May
3, 2019 Federal Register (84 FR 19086).
Section 9.3.4 of this chapter describes
how OMHA appeal numbers are
assigned for new appeals. This revision
adds a note clarifying that if a single
request for hearing or review identifies
more than one reconsideration number,
OMHA will process each
reconsideration number as a separate
request for purposes of assigning appeal
numbers, but will assign the appeals to
the same adjudicator to the extent
possible for administrative efficiency.
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OCPM Chapter 14: Scheduling and
Noticing for Prehearing Conferences and
Hearings—Sections 14.5.4, 14.6.7.4
This chapter was initially released on
September 28, 2018, and was included
in a quarterly notice published in the
November 14, 2018 Federal Register (83
FR 56859). Section 14.5.4 is revised to
clarify that CMS has designated the
AdQIC to receive notices of hearing.
Section 14.6.7.4 of this chapter
describes when the hearing format may
be changed. Previously, this section
stated that if a party other than an
unrepresented beneficiary who filed a
request for hearing requests a VTC
hearing or in-person hearing,
concurrence of the Associate Chief ALJ
was necessary to grant the request. This
revision clarifies that the concurrence of
the Associate Chief ALJ is only required
to grant a request for an in-person
hearing.
OCPM Chapter 18: Requests for
Information and Remands—Sections
18.1.1.2, 18.1.5, 18.1.7.2, 18.2.2, 18.4.3
This chapter was initially released on
November 30, 2018, and was included
in a quarterly notice published in the
January 31, 2019 Federal Register (84
FR 763). Sections 18.1.1.2 and 18.1.5 of
this chapter describe how an OMHA
adjudicator may issue a request for
information if he or she believes that the
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written record is missing information
essential to resolving the issues on
appeal. This revision clarifies that a
request for information may be made for
an official copy of a dismissal of a
request for redetermination or
reconsideration. Section 18.1.7.2 of this
chapter lists actions an OMHA
adjudicator may take if the missing
information is not submitted within the
applicable time frame. This revision
added a note that a remand is
authorized when the entity that
conducted the reconsideration does not
respond to a request for a case file, or
does respond but is unable to furnish
the requested case file. This note further
states that case file requests are not
requests for information made under 42
CFR 405.1034(a) or 423.2034(a). Rather,
as discussed at 84 FR 19866, they are
made in accordance with joint operating
procedures between OMHA and the
entity that conducted the
reconsideration. Section 18.2.2 of this
chapter explains that if the missing
information is not provided, an OMHA
adjudicator may remand the appeal.
This revision clarifies that if an official
copy of a dismissal of a request for
redetermination or reconsideration is
not received, an OMHA adjudicator may
issue a remand to the entity that
conducted the reconsideration, or its
successor, to reconstruct the record or,
if unable to do so, initiate a new appeal
adjudication. Section 18.4.3 of this
chapter explains the circumstances
under which a remand may be
reviewed. This revision clarifies that a
remand issued because an official copy
of a dismissal of a request for
redetermination or reconsideration or
case file cannot be obtained from the
QIC may be subject to review by the
Chief ALJ or designee in accordance
with revisions to 42 CFR 405.1056(g)
and 423.2056(g) that became effective
on July 8, 2019 (84 FR 19866).
OCPM Chapter 20: Post-Adjudication
Actions—Sections 20.7.1.3, 20.7.5.6,
20.7.7.3, 20.8.4, 20.8.5.6, 20.8.6.1,
20.8.7.2, 20.11.4
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).
Sections 20.7.1.3 and 20.7.5.6 of this
chapter previously stated a dismissal
may be vacated within 6 months of the
date of the notice of dismissal. This
revision updates the time frame from 6
months to 180 calendar days in
accordance with revisions to 42 CFR
405.1052(e) and 423.2052(e) that
became effective on July 8, 2019 (84 FR
19857). Section 20.7.7.3 of this chapter
updates the form number for the Order
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Vacating Dismissal from OMHA–180 to
OMHA–181. Section 20.8.4 of this
chapter is revised to clarify that a
request for review of a remand may only
be filed with OMHA Central Operations.
Section 20.8.5.6 of this chapter is
revised to clarify that requests for a copy
of administrative records are made
directly through OMHA Central
Operations. Section 20.8.6.1 of this
chapter removed an incorrect statement
that an OMHA adjudicator must make a
request for information before issuing a
remand for a missing case file. The
remand order is authorized under 42
CFR 405.1056(a)(2). Chapter 20.8.7.2 of
this chapter is revised to clarify that the
re-established appeal number is used
with the Notice of Vacated Remand and
Order Vacating Remand. Chapter
20.11.4 of this chapter describes how an
adjudicator responds to a Council
remand order for missing evidence or
information. Previously, this section
stated that if the adjudicator is able to
furnish the requested evidence or
information, the complete
administrative record was returned to
the Council at the address specified in
the Council’s remand order. This
revision states the records shall be
returned to the Council at the address
specified in OCPM 19.1.2.
Dated: December 31, 2019.
Karen W. Ames,
Executive Director, Office of Medicare
Hearings and Appeals.
[FR Doc. 2019–28504 Filed 1–3–20; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
National Institutes of Health
National Institute of Allergy and
Infectious Diseases; Notice of Closed
Meeting
Pursuant to section 10(d) of the
Federal Advisory Committee Act, as
amended, notice is hereby given of the
following meeting.
The meeting will be closed to the
public in accordance with the
provisions set forth in sections
552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
as amended. The contract proposals and
the discussions could disclose
confidential trade secrets or commercial
property such as patentable material,
and personal information concerning
individuals associated with the contract
proposals, the disclosure of which
would constitute a clearly unwarranted
invasion of personal privacy.
Name of Committee: National Institute of
Allergy and Infectious Diseases Special
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06JAN1
]]>Agencies
[Federal Register Volume 85, Number 3 (Monday, January 6, 2020)]
[Notices]
[Pages 510-512]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-28504]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1903-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--July Through September 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 July through September
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: Jon Dorman, by telephone at (571) 457-
7220, or by email at [email protected].
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
[[Page 511]]
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
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 July Through September 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 July through
September 2019. This information is available on our website at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/.
General OCPM Updates
OMHA reorganized its Program Evaluation and Policy Division and
Field Operations Division into two branches of a new Appeals Policy and
Operations Division. References to the prior division names in OCPM
chapters 6, 7, 11, 18, and 20 were updated to reflect the change in
OMHA's organizational structure.
CMS's final rule entitled ``Medicare Program; Changes to the
Medicare Claims and Medicare Prescription Drug Coverage Determination
Appeals Procedures'' was published in the May 7, 2019 Federal Register
(84 FR 19855) with an effective date of July 8, 2019. This final rule
made a number of changes to help streamline the appeals process and
reduce administrative burden, and to help ensure the regulations are
clearly arranged and written to give stakeholders a better
understanding of the appeals process. Among other things, these
regulations corrected and clarified cross references, definitions, and
terminology. To implement these changes, revisions were made to
footnotes and citations in OCPM 9.3.6.1, 11.3.6.3, 17.1.5, 17.1.5.3 and
17.2.2.
OCPM Chapter 4: Parties--Section 4.4.1.1
This chapter was initially released on March 29, 2019, and was
included in a quarterly notice published in the May 3, 2019 Federal
Register (84 FR 19086). Section 4.4.1.1 of this chapter states that a
Unified Program Integrity Contractor (UPIC) cannot elect party status
in an appeal, and may only participate as a non-party. As initially
published, this section cited to CMS's Medicare Program Integrity
Manual (MPIM), internet-only manual publication 100-08, chapter 4,
section 4.8.2, which previously stated that a Zone Program Integrity
Contractor (ZPIC) could not elect party status in an appeal, and
section 4.1, which stated that all references to ZPICs shall also apply
to UPICs, unless otherwise specified in the UPIC Statement of Work
(SOW). Effective October 22, 2018, CMS revised the MPIM to directly
state that a UPIC cannot invoke party status, and can only participate
in OMHA proceedings as a non-party. This revision to OCPM 4.4.1.1
updates a footnote in this section to reflect the CMS manual's revised
language. This revision does not change the way that OMHA interprets or
implements the underlying policy that a UPIC cannot elect party status.
OCPM Chapter 5: Representatives--Section 5.2.1.2
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). Section 5.2.1.2 of this chapter lists
the required elements for a valid appointment of representative. This
revision updates the required elements in accordance with revisions to
42 CFR 405.910(c) that became effective on July 8, 2019 (84 FR 19857
through 19858), and corresponding updates to CMS's Medicare Claims
Processing Manual (MCPM), internet-only manual publication 100-04,
chapter 29, section 270.1.2.
OCPM Chapter 6: CMS, CMS Contractor, and Plan Roles--Sections 6.5.3.1,
6.5.4.1, 6.5.10, 6.7.3.1, 6.7.3.3, 6.7.4
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). Section 6.5.3.1 of this chapter
previously stated that in a Part A, Part B, or Part C appeal, CMS or a
CMS contractor may elect to be a party or non-party participant no
later than 10 calendar days after ``receiving the notice of hearing.''
This revision implements changes to 42 CFR 405.1010(b)(3)(ii) and
405.1012(a)(1) (84 FR 19862), and clarifies that the notice of hearing
may be received by the Qualified Independent Contractor (QIC) or
another contractor designated by CMS to receive the notice of hearing.
Section 6.5.4.1 of this chapter is revised to clarify that CMS has
designated the Administrative Qualified Independent Contractor (AdQIC)
to receive notices of hearing. Sections 6.5.10 and 6.7.4 of this
chapter previously stated written CMS or contractor elections and
requests and evidentiary submissions must be sent to the parties who
were sent a copy of the
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reconsideration, if no hearing has been scheduled; or the parties who
were sent a copy of the notice of hearing, if a hearing has been
scheduled. This revision implements changes to 42 CFR 405.1010(b)(1)
(84 FR19862), and identifies the copy requirement for appeals where an
appeal has been escalated to OMHA, but has not been scheduled. Sections
6.7.3.1 and 6.7.3.3 of this chapter are revised to clarify that an
attorney adjudicator may also grant additional time for submissions.
OCPM Chapter 9: Request and Correspondence Intake, Docketing, and
Assignment--Section 9.3.4
This chapter was initially released on February 1, 2019, and was
included in a quarterly notice published in the May 3, 2019 Federal
Register (84 FR 19086). Section 9.3.4 of this chapter describes how
OMHA appeal numbers are assigned for new appeals. This revision adds a
note clarifying that if a single request for hearing or review
identifies more than one reconsideration number, OMHA will process each
reconsideration number as a separate request for purposes of assigning
appeal numbers, but will assign the appeals to the same adjudicator to
the extent possible for administrative efficiency.
OCPM Chapter 14: Scheduling and Noticing for Prehearing Conferences and
Hearings--Sections 14.5.4, 14.6.7.4
This chapter was initially released on September 28, 2018, and was
included in a quarterly notice published in the November 14, 2018
Federal Register (83 FR 56859). Section 14.5.4 is revised to clarify
that CMS has designated the AdQIC to receive notices of hearing.
Section 14.6.7.4 of this chapter describes when the hearing format may
be changed. Previously, this section stated that if a party other than
an unrepresented beneficiary who filed a request for hearing requests a
VTC hearing or in-person hearing, concurrence of the Associate Chief
ALJ was necessary to grant the request. This revision clarifies that
the concurrence of the Associate Chief ALJ is only required to grant a
request for an in-person hearing.
OCPM Chapter 18: Requests for Information and Remands--Sections
18.1.1.2, 18.1.5, 18.1.7.2, 18.2.2, 18.4.3
This chapter was initially released on November 30, 2018, and was
included in a quarterly notice published in the January 31, 2019
Federal Register (84 FR 763). Sections 18.1.1.2 and 18.1.5 of this
chapter describe how an OMHA adjudicator may issue a request for
information if he or she believes that the written record is missing
information essential to resolving the issues on appeal. This revision
clarifies that a request for information may be made for an official
copy of a dismissal of a request for redetermination or
reconsideration. Section 18.1.7.2 of this chapter lists actions an OMHA
adjudicator may take if the missing information is not submitted within
the applicable time frame. This revision added a note that a remand is
authorized when the entity that conducted the reconsideration does not
respond to a request for a case file, or does respond but is unable to
furnish the requested case file. This note further states that case
file requests are not requests for information made under 42 CFR
405.1034(a) or 423.2034(a). Rather, as discussed at 84 FR 19866, they
are made in accordance with joint operating procedures between OMHA and
the entity that conducted the reconsideration. Section 18.2.2 of this
chapter explains that if the missing information is not provided, an
OMHA adjudicator may remand the appeal. This revision clarifies that if
an official copy of a dismissal of a request for redetermination or
reconsideration is not received, an OMHA adjudicator may issue a remand
to the entity that conducted the reconsideration, or its successor, to
reconstruct the record or, if unable to do so, initiate a new appeal
adjudication. Section 18.4.3 of this chapter explains the circumstances
under which a remand may be reviewed. This revision clarifies that a
remand issued because an official copy of a dismissal of a request for
redetermination or reconsideration or case file cannot be obtained from
the QIC may be subject to review by the Chief ALJ or designee in
accordance with revisions to 42 CFR 405.1056(g) and 423.2056(g) that
became effective on July 8, 2019 (84 FR 19866).
OCPM Chapter 20: Post-Adjudication Actions--Sections 20.7.1.3,
20.7.5.6, 20.7.7.3, 20.8.4, 20.8.5.6, 20.8.6.1, 20.8.7.2, 20.11.4
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). Sections 20.7.1.3 and 20.7.5.6 of this chapter
previously stated a dismissal may be vacated within 6 months of the
date of the notice of dismissal. This revision updates the time frame
from 6 months to 180 calendar days in accordance with revisions to 42
CFR 405.1052(e) and 423.2052(e) that became effective on July 8, 2019
(84 FR 19857). Section 20.7.7.3 of this chapter updates the form number
for the Order Vacating Dismissal from OMHA-180 to OMHA-181. Section
20.8.4 of this chapter is revised to clarify that a request for review
of a remand may only be filed with OMHA Central Operations. Section
20.8.5.6 of this chapter is revised to clarify that requests for a copy
of administrative records are made directly through OMHA Central
Operations. Section 20.8.6.1 of this chapter removed an incorrect
statement that an OMHA adjudicator must make a request for information
before issuing a remand for a missing case file. The remand order is
authorized under 42 CFR 405.1056(a)(2). Chapter 20.8.7.2 of this
chapter is revised to clarify that the re-established appeal number is
used with the Notice of Vacated Remand and Order Vacating Remand.
Chapter 20.11.4 of this chapter describes how an adjudicator responds
to a Council remand order for missing evidence or information.
Previously, this section stated that if the adjudicator is able to
furnish the requested evidence or information, the complete
administrative record was returned to the Council at the address
specified in the Council's remand order. This revision states the
records shall be returned to the Council at the address specified in
OCPM 19.1.2.
Dated: December 31, 2019.
Karen W. Ames,
Executive Director, Office of Medicare Hearings and Appeals.
[FR Doc. 2019-28504 Filed 1-3-20; 8:45 am]
BILLING CODE 4150-46-P
