TN 2 (07-14)
GN 03108.210 Title XVIII Entitlement Appeals Procedures
A. Overview of what constitutes a Medicare entitlement determination
Determinations as to whether an individual meets the requirements for entitlement to Medicare Part A (Hospital Insurance, HI); e.g., age, entitlement to monthly benefits, application requirements, insured status, and for enrollment under Medicare Part B (Supplementary Medical Insurance, SMI) are for purposes of these instructions considered “entitlement” determinations.
Any individual who is dissatisfied with an initial determination of health insurance entitlement (Part A or B) has the same appeal rights and may follow the same appeal procedures as in a claim under title II of the Act (see GN 03101.001). A beneficiary may request a reconsideration, hearing before an Administrative Law Judge (ALJ), Medicare Appeals Council (MAC) review, and ultimately, seek judicial relief if he or she remains dissatisfied with the determination.
B. Handling a request for reconsideration
SSA is responsible for processing a request for reconsideration of an entitlement determination. Send requests for reconsideration of an entitlement determination for Medicare Part A or Part B to the servicing processing center (PC) following current procedure in GN 03102.175B.2. If the beneficiary is a qualified RRB annuitant (QRRB's), RRB is responsible for handling the appeal request. Instructions for handling reconsiderations filed by QRRB’s are in GN 03101.150B.2.
C. Procedure for processing a hearing request
As of July 1, 2005, the Department of Health and Human Services (HHS) Office of Medicare Hearing and Appeals (OMHA) has handled all non-medical entitlement hearings for Medicare Part A and B. Beneficiaries can still file a hearing request with the Social Security (SSA) field office (FO) or call the National 800 Number Network (N8NN) to request the appropriate forms for filing a hearing request. Southeastern Program Service Center (SEPSC) is responsible for sending all hearing requests to the OMHA. All hearing requests received by the N8NN, FO or PC, other than SEPSC should follow the instructions below.
1. 800 number agent action
Send the beneficiary Form HA-501-U5 (Request for Hearing by Administrative Law Judge). Include an envelope addressed to: Southeastern Program Service Center
Att. Inquiries and Expediting
1200 Rev. Abraham Woods, Jr. Blvd
Birmingham, AL 35285
2. Field office and all processing centers (except SEPSC) action
Mail all requests received to: Southeastern Program Service Center
Att. Inquiries and Expediting
1200 Rev. Abraham Woods, Jr., Blvd
Birmingham, AL 35285
3. SEPSC Inquiries and Expediting Senior Claims Processing Specialist (SEPSC I&E SCPS) action
Input Special Message on the Master Beneficiary Record (MBR) indicating the receipt date of the Medicare hearing request
Scan the “Medicare Appeals (Hearing level) – Checklist” into Paperless under TOELS HISMI APPEAL
Prepare a paper file including the items needed according to the “Medicare Appeals (Hearing level) – Checklist”
Ship the file to HHS OMHA Administrative Law Judge (ALJ) at: HHS OMHA Centralized Docketing
200 Public Square, Suite 1260
Cleveland, OH 44114-2316
Update the Special Message on the MBR showing the date the appeal was shipped to OMHA
D. Responsibility for effectuating an OMHA decision
The SEPSC inquiries and expediting senior claims processing specialist (I&E SCPS) is responsible for the effectuation of an OMHA ALJ Medicare Entitlement decision. When a decision is received, the SEPSC I&E SCPS will either take no adjudicative action, effectuate the decision, or protest the ALJ decision to the MAC within the allotted period.
E. Processing an affirmation decision from OMHA ALJ (SEPSC only)
If the ALJ decision is an affirmation of SSA’s decision, update the Special Message on the MBR documenting the date of the hearing and the ALJ decision.
F. Processing a reversal decision from OMHA ALJ (SEPSC only)
If the ALJ decision is a reversal of SSA’s decision and the decision is not contrary to the law and regulations and there is no reason for SSA to protest the decision, update the Special Message on the MBR documenting the date of the hearing and the ALJ decision. Effectuate the decision. Record the decision in paperless and send the action control record (ACR) to Files In (FIN).
G. Protesting an Administrative Law Judge decision (SEPSC only)
If there is reason to believe the ALJ decision is incorrect, SSA will protest the decision. The I&E SCPS will prepare a protest memo for SEPSC OAS review and send the ACR to SEPSC OAS. SEPSC Operations Analysis Section (OAS) forwards the protest memo to the Office of Income Security Programs (OISP) and the Office of the General Counsel (OGC) for concurrence. SEPSC OAS analyst will control, on a weekly basis, to insure SEPSC submits the protest to the MAC no later than the 40th day after the ALJ decision. Upon concurrence from OISP and OGC, OAS will return the ACR to I&E SCPS. I&E SCPS will send the ALJ protest memo to the MAC at: Department of Health and Human Services
Departmental Appeals Board
Medicare Appeals Council, MS 6127
Cohen Building Room G-644
330 Independence Ave., S.W.
Washington, D.C. 20201
SEPSC will send a copy of the protest letter to the beneficiary with a cover notice explaining our action.
H. Effectuation of an Medicare Appeals Council (MAC) decision (SEPSC only)
SEPSC I&E SCPS is responsible for updating the Special Message on the MBR reflecting the MAC decision. If the MAC affirms the ALJ decision, SEPSC I&E SCPS is responsible for the effectuation of the decision.