OMHA: New Changes Designed to Improve Medicare Appeals Process

OMHA Issues Updates to Its Case Processing Manual

The Office of Medicare Hearings and Appeals (OMHA) announced updates to its OMHA Case Processing Manual (OCPM), which was first released in 2015.

The purpose of the OCPM is to standardize and memorialize the day-to-day procedures for carrying out adjudicative functions in accordance with applicable statutes, regulations, and OMHA directives. Periodically, the OCPM undergoes revision to reflect changes to the Medicare appeals process following revised regulations, or to provide clearer guidance and instruction to appellants, adjudicators, and OMHA staff.

On July 15, 2018, OMHA published two new and four revised chapters of the OCPM.

All of the chapters now include a “chapter overview” at the beginning that outlines the basic structure and content of each chapter. Previously, the manual was divided into multiple parts, each with its own respective sub-chapters: Division 1: General Matters; Division II: Part A/B Claim Determinations; Division III: Part C Organization Determinations; Division IV: Part D Organization Determinations; and Division V: SSA Determinations. The updated version is no longer organized by divisions; rather, it contains 20 consecutive chapters. These recent updates reflect OMHA’s effort to make the manual easier to read and comprehend, and to reflect recent regulatory changes. The new or revised chapters are 1, 5, 6, 7, 19, and 20.

Chapters 1 and 20 are new chapters, which became effective on May 25, 2018. Chapter 1 in the 2017 version of the manual is titled “Manual Overview, Definition, and Governance,” just as that of the new version. However, the new Chapter 1 addresses the revised organization of the manual and how to navigate it in the context of the elimination of the four divisions. While both versions of Chapter 1 address the general purpose of the manual, how to cite the manual, and acronyms used within the manual, the content in the organization section of this chapter has drastically changed.

Chapter 20 is an entirely new chapter that did not exist in prior versions of the OCPM. Chapter 20, “Post-Adjudication Actions,” discusses the actions that appellants may take after a decision, dismissal, or remand is issued, and how adjudicators may process such actions or take such actions on their own motion.

More specifically, post-adjudication actions include effectuating a final decision, updating the administrative record, correcting clerical errors, re-openings, requests to vacate dismissals, remands, and other matters. Prior versions of the OCPM did not contain the same level of detail on the various types of post-adjudication actions and how to properly process them.

OMHA revised chapters 5, 6, 7, and 19 from the 2017 manual, and they became effective on July 27, 2018. While these chapters retained much of the same content, OMHA modified the organization of the chapters. The most noticeable change is that the structure shifted from a term-and-definition approach to a question-and-answer approach, promoting ease of use for readers.

Chapter 5 is titled “Representatives” and describes the role of representatives in the appeals process, including the qualifications and responsibilities of representatives and how to validly effectuate, delegate, or revoke the appointment of a representative. Recent revisions to this chapter include modifying the structure of the manual to a more user-friendly question-and-answer format.

Chapter 6 is titled “CMS (the Centers for Medicare & Medicaid Services), CMS Contractor, Plan Roles” and describes when and how CMS, a CMS contractor, or a plan may join the proceedings; it also describes the requirements for a valid election or request to participate, as well as when evidence and other documentation may be submitted by CMS, a CMS contractor, or a plan. The revised chapter incorporates the revisions to the federal regulations that became effective on March 20, 2017 governing party- and non-party participation in administrative law judge (ALJ) hearings. For example, the revised chapter explains that contractors may elect to participate in an ALJ hearing either within 30 calendar days after notification that a request for a hearing was filed, or within 10 calendar days of receipt of a notice of hearing.

Chapter 7 is titled “Adjudication Time Frames, Case Prioritization, and Escalations” and describes when adjudication may be extended, delayed, or even waived, in certain circumstances. The chapter also makes clear that if an adjudication time frame is not met, then a party appealing a reconsideration decision may escalate the appeal to the Medicare Appeals Council. The recent revisions provide a more linear explanation of the adjudication time frames as compared to the prior OCPM. For example, the revised manual asks, “what is the adjudication time frame for a Part A or Part B appeal?” and then specifies the exact adjudication time frame at each level of appeal (and under different adjudication circumstances, such as remand or escalation).

The previous iteration of the manual concluded each division with a “closing the case” section, which explained how to properly dispose of and close an appeal. Under the revised OCPM, OMHA consolidated these sections into Chapter 19, titled “Closing the Case,” which provides specific guidance on the multi-step process for doing just that in a timely and correct manner.

These additions and revisions to the OCPM make it an important tool for both appellants and adjudicators to efficiently participate in the Medicare appeals process. Appellants should familiarize themselves with the OCPM, which appears on OMHA’s website, as it provides best-practice tips and instructions for participating in the appeals process.

The revised OCPM improves the functionality of the manual through reorganized content and more detailed guidance for both appellants and adjudicators.

With clearer instructions and updates to account for recently revised regulations, the new changes should help improve efficiencies in the Medicare appeals process.