Content created by Office of Medicare Hearings and Appeals (OMHA)
On this page: Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | Chapter 7 | Chapter 8 | Chapter 9 | Chapter 10 | Chapter 11 | Chapter 12 | Chapter 13 | Chapter 14 | Chapter 15 | Chapter 16 | Chapter 17 | Chapter 18 | Chapter 19 | Chapter 20
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.
Chapter 1
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Manual Overview, Definition, and Governance | Initial Release | 5/25/2018 |
Chapter 2
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Information Disclosure | Initial Release | 6/17/2020 |
| Chapter 2 Information Disclosure material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||
Chapter 3
Adjudicators, Authorities, Burdens, and Standards of Review
Chapter 4
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Parties - 12092021 | 4.4.1.3: Revised to replace inoperative hyperlinks. | 12/9/2021 |
| 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 - 12092021 | 5.2.1.2, 5.4.1, 5.4.3: Revised to replace inoperative hyperlinks. | 12/9/2021 |
| 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 - 12092021 | 7.1.1.1, 7.1.1.2, 7.1.4.1, 7.2.1, 7.2.2, 7.3.1, 7.3.2, 7.3.4, 7.4.3, 7.5.2, 7.5.4, 7.5.5, 7.5.6, 7.5.8, 7.5.9: Revised to replace inoperative hyperlinks. | 12/9/2021 |
| 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 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
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Party and Non-Party Participant Requests and Submissions - 12092021 | 10.5.2, 10.5.3, 10.7.10.1, 10.7.11, 10.7.11.1, 10.7.11.2: Revised to replace inoperative hyperlinks. | 12/9/2021 |
| Party and Non-Party Participant Requests and Submissions | Initial Release | 2/19/2020 |
| Chapter 10 Party and Non-Party Participant Requests and Submissions is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||
Chapter 11
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Procedural Review and Determinations - 12092021 | 11.3.2, 11.4.5: Revised to update the minimum amount in controversy to reflect the ten most recent calendar years; replace inoperative hyperlinks. | 12/9/2021 |
| 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
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Administrative Record and Exhibiting | Initial Release | 10/28/2022 |
| Chapter 12 Administrative Record and Exhibiting material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||
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
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Conducting Conferences and Hearings; Posthearing Development | Initial Release | 11/21/2019 |
| Chapter 15 Conducting Conferences and Hearings; Posthearing Development material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||
Chapter 16
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Decisions - 12092021 | 16.4.3: Revised footnote 15 to reflect the revised regulation at 42 C.F.R. § 422.562(d)(3). | 12/9/2021 |
| Decisions | Initial Release | 10/09/2019 |
| Chapter 16 Decisions material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||
Chapter 17
| Chapter Name | Revision Updates | Publish Date |
|---|---|---|
| Dismissals - 12092021 | 17.1.4, 17.1.5.2, 17.1.5.4, 17.1.11.1, 17.2.1: Revised to replace inoperative hyperlinks. | 12/9/2021 |
| 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 - 09212023 * | 20.2.1, 20.2.2, 20.3.2, 20.3.4, 20.4.1, 20.4.3, 20.4.4, 20.4.5, 20.4.6, 20.5.2, 20.5.3, 20.5.4, 20.5.5 (multiple), 20.5.7(multiple), 20.5.8 (multiple), 20.6.1 (multiple), 20.6.2, 20.6.4, 20.6.5 (multiple), 20.6.6.1, 20.6.7 (multiple), 20.7.1.4, 20.7.2, 20.7.4, 20.7.5 (multiple), 20.7.7 (multiple), 20.8.1.3, 20.8.2, 20.8.4, 20.8.5 (multiple), 20.8.6.1, 20.8.7 (multiple), 20.9.1, 20.9.2, 20.9.4, 20.9.5, 20.10.2, 20.10.3, 20.11.2, 20.11.4, 20.11.5, 20.11.6, 20.12.1, 20.12 (multiple), 20.13: Revised to address changes to post-adjudication appeals processing resulting from ECAPE processing, the e-Appeal Portal, and other improvements in appeals operations and processing; revised to remove relatively rare MAS data entry and updating processes; revised to remove secondary approvals for various post-adjudication actions; revised to clarify the distinction between updating the administrative record for ECAPE appeals and non-ECAPE appeals; revised to clarify that if the original adjudicator is not available for more than 20 calendar days, the ACALJ reviews post-adjudication requests and if they decide to grant the request then the appeal is reassigned to the ACALJ; revised to clarify how various post-adjudication requests are filed; revised to update the process to re-establish an appeal; revised to clarify that an adjudicator may not reopen a decision or vacate a dismissal if an appeal is pending with the Council; added new order, Order Denying Review of Request to Vacate a Remand (OMHA-188T), and revised existing order OMHA-189T; revised to clarify that CMS contractor responses to an OMHA remand are not reviewable and appeals are immediately re-established; added new form for Returnable Remand Notice (OMHA-383T); added new section, 20.13, Requests to Obtain Approval of a Fee. | 9/21/2023 |
| Post-Adjudication Actions - 12092021 | 20.1.4, 20.2.2, 20.4.3, 20.5.3, 20.6.2, 20.6.3.1, 20.6.3.2, 20.6.6.1, 20.6.8, 20.7.1.2, 20.7.1.3, 20.7.1.5, 20.7.2, 20.7.3.1, 20.7.8, 20.8.1.2, 20.8.1.4, 20.8.1.5, 20.8.1.6, 20.8.2, 20.8.3.1, 20.8.3.2, 20.8.3.3, 20.10.4; 20.5.3, 20.6.4, 20.7.4, 20.8.4, 20.9.2, 20.11.2: Revised to replace inoperative hyperlinks; revised to update the OMHA Central Operations mailing address. | 12/9/2021 |
| 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 |
| * Chapter 20 Post-Adjudication Actions material is undergoing Section 508 Review. Please contact OMHAPolicy@hhs.gov for assistance. | ||