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, refer to 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), RRB is responsible for handling the appeal request. Instructions for handling reconsiderations filed by QRRBs 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.

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 either:

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  takes no adjudicative action,

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  effectuates the decision, or

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  protests the ALJ decision to the MAC within the allotted period depending on the results of the decision.

Remands are returned to the PC (or module) of jurisdiction for a reconsideration determination as SEPSC I&E is not responsible for reconsideration-level appeals for Medicare issues, unless there is another reason for SEPSC I&E to assume jurisdiction (i.e. PC3 jurisdiction with congressional interest).

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 Program Policy and Data Exchange (LP PPDX) and Program Litigation (LP PL) for concurrence. SEPSC OAS analyst must control, on a weekly basis, to ensure SEPSC submits the protest to the MAC no later than the 40^th day after the ALJ decision. Upon concurrence from LP PPDX and LP PL, OAS returns the ACR to the I&E CTE. The 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.

The 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, the SEPSC I&E CTE is responsible for the effectuation of the decision.