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The Office of Medicare Hearings and Appeals (OMHA) is the agency that administers the Administrative Law Judge (ALJ) hearing program for Medicare Parts A, B, C and D appeals. OMHA has a Case Processing Manual that sets out day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations, and OMHA directives. Importantly for many, it gives the staff at OMHA direction for processing ALJ appeal requests.

Most recently, on February 1, 2019, OMHA released the revised Chapter 9 that addresses “Request and Correspondence Intake, Docketing, and Assignment.” (See: https://www.hhs.gov/sites/default/files/request-and-correspondence-intake-docketing-and-assignment-02-01-2019.pdf).

The Case Processing Manual can help answer questions not otherwise found in applicable statutes, regulations or Centers for Medicare & Medicaid Services (CMS) Policy Manuals. For example, we recently had an inquiry from a beneficiary asking how to consolidate two separate appeals that dealt with two different services from two different providers, but with both services related to the same condition. Other than requesting aggregation to meet the amount in controversy requirement, which was not the issue in this case, we found no answer in the regulations or CMS Policy Manual. However the Case Processing Manual, provided some answers.  Chapter 9, section 9.3.6.2 discusses how to group appeals and appears to provide some guidance when an appellant requests that cases be consolidated prior to ALJ assignment. The Case Processing Manual chapters also addresses, among other things, issues such as the role of representatives in the appeals process, case prioritization, the administrative record, and the scheduling and noticing for pre-hearing conferences and hearings.

The Case Processing Manual is an excellent resource. New and revised chapters can be accessed at https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/index.html. Chapters that were published before May 10, 2018, can be accessed at: https://www.hhs.gov/about/agencies/omha/the-appeals-process/case-processing-manual/2017/index.html.

February 14, 2019 – M. Ashkar

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