Tuesday, July 14, 2015

OMHA Releases Case Processing Manual

Qingping Wang

The Office of Medicare Hearings and Appeals (OMHA) has announced the implementation of a new OMHA Case Processing Manual (OCPM). The OCPM establishes the “day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations and OMHA directives,” according to OMHA.

The new OCPM contains updates of procedures in the following five divisions:

1) Division I: General Matters;
2) Division II: Part A/B Claims Determinations;
3) Division III: Part C Organization Determinations;
4) Division IV: Part D Coverage Determinations; and
5) Division V: SSA Determinations.

The update adds a new chapter under Division I to provide a general overview of the manual. The new OCPM also contains updates on the current requirements and procedures for determination of valid appeals, including proper jurisdiction, standing, minimum amount in controversy, timely filing and other additional requirements.

OMHA is a division within the Office of the Secretary of the U.S. Department of Health and Human Services (HHS). It administers hearings of Medicare appeals at the levels of Administrative Law Judge (ALJ) and the Departmental Appeals Board (DAB). In addition, OMHA addresses disagreements with coverage and payment determinations related to Medicare eligibility, Part B late enrollment penalty, and income related monthly adjustment amounts made by the Social Security Administration. Over the last several years, the number of ALJ appeals filed has increasingly grown, resulting in a significant backlog. OMHA developed the OCPM to improve consistency among adjudicators and to provide a framework for the move to electronic case processing.

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