Beneficiary Appeals Data

To help ensure Medicare Beneficiary, Part C Medicare Advantage Plan Enrollee and Part D Plan Enrollee appeals are adjudicated as quickly as possible, OMHA designates them as priority appeals. More information on the OMHA Beneficiary and Enrollee prioritization policy is available here.

OMHA’s goal is to adjudicate Beneficiary and Enrollee appeals within 90 days, unless another time frame applies (for example, Part D appeals that qualify for an expedited hearing are adjudicated within 10 days). However, we recognize that not all appeals can be resolved in that time frame. For example, a Beneficiary or representative may request additional time to gather documentation or be unable to commit to a hearing date for an extended period of time, or the complexity of the issue involved may require additional time for the OMHA adjudicator to prepare for the hearing or issue a decision.

The information below provides the public with data on OMHA’s processing of Beneficiary and Enrollee appeals. We present information on the average length of time for Beneficiary and Enrollee appellants to receive decisions based on the fiscal year in which the appeal is filed (note, fiscal years run from October 1 to September 30). We also present information on the number and average age of any pending appeals filed in those years. For pending appeals, we also provide data on where the appeals are in the process if they have gone past the 90 day goal.

If you are a Beneficiary or Enrollee, or a Beneficiary or Enrollee representative, and are experiencing delays in the OMHA adjudication process, assistance is available at the toll-free OMHA Beneficiary Help Line, at (844) 419-3358. The OMHA Beneficiary Help Line is staffed from 8:00 a.m. to 4:30 p.m. Eastern Time. During other hours, or if the OMHA Beneficiary Help Line representatives are assisting other callers, please leave a voicemail and your call will be returned as quickly as possible. In addition, certain appeals may be escalated to the Medicare Appeals Council for review when the 90 day time frame is not met. More information on the escalation process is available here.

 

Data for Appeals of Part A and Part B QIC reconsiderations, and Part D IRE reconsiderations (A/B QIC, D IRE)

Type FY 2019 FY 2018 FY 2017 FY 2016 FY 2015

Appeals Filed3,4

2,617 3,375 3,442 3,741 3,512

Pending Appeals

613 4 1 0 1

Average Age Pending (days)5

49.6 349.3 751.0 0 1,475.0

Decided Appeals6

2,004 3,371 3,439 3,740 3,506

Wait Time to Decision (days)6

65.8 75.3 74.8 80.2 94.3

Data for Appeals of SSA reconsiderations, QIO reconsiderations, and Part C IRE reconsiderations (QIO, C IRE)

Type FY 2019 FY 2018 FY 2017 FY 2016 FY 2015

Appeals Filed3,4

2,531 2,994 3,235 2,927 2,484

Pending Appeals

640 7 0 0 0

Average Age Pending (days)5

48.1 445.0 0 0 0

Decided Appeals6

1,891 2,987 3,235 2,926 2,484

Wait Time to Decision (days)6

66.7 74.7 74.0 80.6 91.6

Comparison between A/B QIC, D IRE and QIO, C IRE Pending Appeals (all FYs)

Overall Pending Appeals A/B QIC and D IRE Appeals1 SSA, QIO and C IRE Appeals2

Pending Appeals

619 647

Average Age (days)5

54.9 52.4

% Tolled/Waived7

14.40% N/A
Pending Appeals Aged 90 Days to 120 Days9 A/B QIC and D IRE Appeals1 SSA, QIO and C IRE Appeals2

Docketed8

0 1

Assigned to an OMHA adjudicator

13 4

Hearing Scheduled

25 7

Hearing Conducted

18 15
Pending Appeals Aged Over 120 Days9 A/B QIC and D IRE Appeals1 SSA, QIO and C IRE Appeals2

Assigned to an OMHA adjudicator

1 4

Hearing Scheduled

6 7

Hearing Conducted

3 8

Data through June 30, 2019.


n.1  Includes appeals of Part A and Part B QIC reconsiderations, and Part D IRE reconsiderations.

n.2  Includes appeals of SSA reconsiderations, QIO reconsiderations, and Part C IRE reconsiderations.

n.3  Includes reopened appeals.

n.4  Includes 6 "combined" appeals that are not separately included in pending and decided appeal data in the above charts.  Combined appeals are appeals that are combined with other appeals for administrative efficiency(that is, the records are consolidated and a single decision is issued in accordance with 42 CFR §§405.1044 or 423.2044).  The earliest filed requiest date is used to determine the age of the resulting appeal when appeals are combined.

n.5  Average age of pending excludes time for which the adjudication time frame is tolled or otherwise extended, and time frames for appeals in which the adjudication time frame is waived, in accordance with the rules applicable to the adjudication time frame for appeals of Part A and Part B QIC reconsiderations at 42 CFR part 405, subpart I; and Part D IRE reconsiderations at 42 CFR part 423, subpart U, and Part D expedited appeals, which operate on a 10 day adjudication time frame.

n.6  “Decided” and “decision” includes appeals for which a decision, dismissal, or remand was issued, the appeal was escalated to the Medicare Appeals Council (if escalation was available), the appeal was removed to Medicare Appeals Council, or Expedited Access to Judicial Review was granted by the Departmental Appeals Board.

n.7  Percentage of appeals for which the adjudication time frame has been tolled or otherwise extended, or for which the adjudication time frame has been waived; adjudication time frames do not apply to appeals of SSA, QIO, and Part C IRE reconsiderations.

n.8  “Docketed” indicates the appeal was received and entered in the OMHA case adjudication processing system.

n.9  For pending appeals aged 90 to 120 days, and over 120 days, and appeal is reported in its current stage. For example if an appeal is 95 days old and the hearing is scheduled but has not yet been conducted, it will be counted in the column for Pending Appeals Aged 90 Days to 120 Days, Hearing Scheduled, because it has been docketed, assigned to an OMHA adjudicator, and is now scheduled for a hearing; the appeal will not be counted in the Docketed and Assigned to an OMHA adjudicator columns because it has passed those stages.

 

Content created by Office of Medicare Hearings and Appeals (OMHA)
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