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OMHA Case Processing Manual (OCPM)


NOTE: OMHA is in the process of drafting new OCPM chapters and revising existing OCPM chapters to reflect changes to the manual’s format and organization. We are also making updates to address changes made by the Medicare appeals final rule that became effective March 20, 2017 (82 Fed. Reg. 4974 (Jan. 17, 2017)). You will find new and revised chapters posted here as they become available. For prior versions, refer to the 2017 Case Processing Manual. Please note that chapter numbering may have changed.

Chapter 1

Chapter Name Revision Updates Publish Date
Manual Overview, Definition, and Governance Initial Release 5/25/2018

Chapter 2

Information Disclosure

Chapter 3

Adjudicators, Authorities, Burdens, and Standards of Review

Chapter 4

Chapter Name Revision Updates Publish Date
Parties - 07122019 4.4.1.1: Revised citations to reflect CMS manual update with direct reference to UPICs 7/12/2019
Parties Initial Release 3/29/2019
Chapter 4 Parties material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 5

Chapter Name Revision Updates Publish Date
Representatives - 07122019 5.2.1.2: Revised required elements of an AOR in accordance with revised 42 C.F.R. section 405.910 and updates to chapter 29, section 270.1.2 of the Medicare Claims Processing Manual 7/12/2019
Representatives Initial Release 7/27/2018

Chapter 6

Chapter Name Revision Updates Publish Date
CMS, CMS Contractor, and Plan Roles - 07122019 6.3.4, 6.5.4.1, 6.5.10, 6.7.3.1, 6.7.3.3, 6.7.4: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division; revised to identify recipients for contractor elections, requests, position papers, and written testimony in appeals escalated to OMHA; revised to clarify that an attorney adjudicator may also grant additional time for submissions; revised to clarify that CMS designated the AdQIC to receive notices of hearing 7/12/2019
CMS, CMS Contractor, and Plan Roles - 05242019 6.3.1.1, 6.3.2: Revised citations to reflect CMS manual update with direct reference to UPICs 5/24/2019
CMS, CMS Contractor, and Plan Roles Initial Release 7/27/2018
Chapter 6 CMS, CMS Contractor, and Plan Roles material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 7

Chapter Name Revision Updates Publish Date
Adjudication Time Frames, Case Prioritization, and Escalations - 07122019 7.4.4.2: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division 7/12/2019
Adjudication Time Frames, Case Prioritization, and Escalations - 03292019 7.4.3: Revised case prioritization policy to include inadvertently omitted language 3/29/2019
Adjudication Time Frames, Case Prioritization, and Escalations Initial Release 7/27/2018
Chapter 7 Adjudication Time Frames, Case Prioritization, and Escalations material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 8

Special Case Processing Procedures

Chapter 9

Chapter Name Revision Updates Publish Date
Request and Correspondence Intake, Docketing, and Assignment - 07122019 9.3.4, 9.3.6.1: Revised to clarify procedure for assigning OMHA appeal numbers when a single request for hearing identifies more than one reconsideration number; revised footnote citations to reflect relocation of Part D AIC provisions in 42 C.F.R. section 423.1970 to new section 423.2006 7/12/2019
Request and Correspondence Intake, Docketing, and Assignment Initial Release 2/01/2019
Chapter 9 Request and Correspondence Intake, Docketing, and Assignment material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 10

Party/Participant Requests and Submissions

Chapter 11

Chapter Name Revision Updates Publish Date
Procedural Review and Determinations - 07122019 11.3.4, 11.3.6.3: Revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division; replace footnote citation to Federal Register with citation to revised 42 C.F.R. section 405.1006(d)(4) 7/12/2019
Procedural Review and Determinations Initial Release 5/24/2019
Chapter 11 Procedural Review and Determinations material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 12

Administrative Record and Exhibiting (See 2017 Case Processing Manual)

Chapter 13

Issues on Appeal and Case Development

Chapter 14

Chapter Name Revision Updates Publish Date
Scheduling and Noticing for Prehearing Conferences and Hearings - 07122019 14.5.4, 14.6.7.4: Added a footnote clarifying that CMS designated the AdQIC to receive notice of hearing; revised to clarify that the concurrence of the Associate Chief ALJ is only required to grant a request for an in-person hearing 7/12/2019
Scheduling and Noticing for Prehearing Conferences and Hearings Initial Release 9/28/2018

Chapter 15

Conducting Conferences and Hearings; Post-Hearing Development

Chapter 16

Decisions

Chapter 17

Chapter Name Revision Updates Publish Date
Dismissals - 07122019 17.1.5, 17.1.5.3, 17.2.2: Revised footnote citations to reflect relocation of Part D AIC provisions in 42 C.F.R. section 423.1970 to new section 423.2006 7/12/2019
Dismissals Initial Release 11/30/2018

Chapter 18

Chapter Name Revision Updates Publish Date
Requests for Information and Remands - 07122019 18.1.1.2, 18.1.5, 18.1.7.2, 18.2.2, 18.4.3: Revised to clarify that a request for information may be made for an official copy of a dismissal of a request for redetermination or reconsideration, a remand may be issued if the requested information is not provided, and such a remand may be subject to review by the CALJ or designee; revised to replace references to OMHA Program Evaluation and Policy Division with references to Appeals Policy and Operations Division 7/12/2019
Requests for Information and Remands Initial Release 11/30/2018

Chapter 19

Chapter Name Revision Updates Publish Date
Closing the Case - 03292019 19.4.3, 19.5.1: Revised to clarify that if an adjudicator issues a consolidated decision, the adjudicator must also consolidate the record and combine the appeals in the case processing system 3/29/2019
Closing the Case Initial Release 5/25/2018
Chapter 19 Closing the Case material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance.

Chapter 20

Chapter Name Revision Updates Publish Date
Post-Adjudication Actions - 07122019 20.5.5.2, 20.7.1.3, 20.7.1.4, 20.7.5.6, 20.7.7.3, 20.8.4, 20.8.5.6, 20.8.6.1, 20.8.7.2, 20.9.1, 20.9.5, 20.10.3, 20.11.4, 20.11.6: Revised to clarify that the re-established appeal number is used on an order vacating a remand; revised to clarify that requests for paper administrative records are made directly with Central Operations; revised to remove an incorrect statement that an ALJ must make a request for information before a remand for a missing case file is authorized under 42 C.F.R. section 405.1056(a)(2); revised time frame for vacating dismissals from 6 months to 180 calendar days in accordance with revised 42 C.F.R. sections 405.1052(e) and 423.2052(e); revised to replace references to OMHA Program Evaluation and Policy Division and Field Operations Division with references to Appeals Policy and Operations Division 7/12/2019
Post-Adjudication Actions Initial Release 5/25/2018

 

Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on July 12, 2019