PROGRAM OPERATIONS MANUAL SYSTEMPart GN – GeneralChapter 031 – AppealsSubchapter 08 – Medicare ProceduresTransmittal No. 3, 10/17/2022
This transmittal updates the policy and procedure due to new Section 1836(b) to add immunosuppressive drug coverage.
Summary of Changes
GN 03108.210 Title XVIII Entitlement Appeals Procedures
Added, "and Part B-ID (Immunosuppressive Drug coverage)".
the section: Updated from "Senior Claims Processing Specialist" (SCPS) to "Claims Technical Expert" (CTE)
H: change the word “an” to “a”
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) and Part B-ID (Immunosuppressive Drug coverage) 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.
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.
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.
Send the beneficiary Form HA-501-U5 (Request for Hearing by Administrative Law Judge). Include an envelope addressed to:
Mail all requests received to:
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:
Update the Special Message on the MBR showing the date the appeal was shipped to OMHA
The SEPSC inquiries and expediting Claims Technical Expert (I&E CTE) is responsible for the effectuation of an OMHA ALJ Medicare Entitlement decision. When a decision is received, the SEPSC I&E CTE take no adjudicative action, effectuate the decision, or protest the ALJ decision to the MAC within the allotted period.
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.
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).
If there is reason to believe the ALJ decision is incorrect, SSA will protest the decision. The I&E CTE 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 must 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 returns the ACR to I&E CTE. I&E CTE sends the ALJ protest memo to the MAC at:
SEPSC must send a copy of the protest letter to the beneficiary with a cover notice explaining our action.
SEPSC I&E CTE is responsible for updating the Special Message on the MBR reflecting the MAC decision. If the MAC affirms the ALJ decision, SEPSC I&E CTE is responsible for the effectuation of the decision.