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OMHA Issues Updates to Its Case Processing Manual

The Office of Medicare Hearings and Appeals (“OMHA”) announced its updates to its OMHA Case Processing Manual (“OCPM”) last week. The OCPM was originally released in 2015 to regulate and codify procedures for adjudicative functions by using statutes, regulations, and OMHA directives as the guideline. The OCPM is revised as needed in order to keep up with changes to the Medicare appeals process. The OCPM seeks to provide clear guidance and instruction to appellants, adjudicators, and OMHA staff.

A new addition to each chapter in the OCPM is a “Chapter Overview” section that summarizes the content of the chapter. The OCPM used to be organized by four separate divisions, each addressing a different topic. The divisions were Part A/B Claim Determinations, Part C Organization Determinations, Part D Organization Determinations, and SSA Determinations. The updated OCPM is no longer organized by divisions, but instead is made up of twenty consecutive chapters. The purpose of eliminating the divisions was to improve the organization of the manual so that it is more user-friendly. The new or revised chapters are: 1, 5, 6, 7, 19, and 20.

The new chapters, 1 and 20, became effective on May 25, 2018. Prior to revision, Chapter 1 was titled “Manual Overview, Definition, and Governance,” which is also the title of the new Chapter 1. Unlike the previous version of the chapter, the updated Chapter 1 sets forth guidance on how to navigate the new organization of the manual. There are still similarities between the two versions; the general purpose of the manual, how to cite the manual, and acronyms used within the manual. However, the content regarding the organization of the manual has been completely redone.

Chapter 20 did not exist in prior versions of the OCPM. Chapter 20, “Post-Adjudication Actions,” sets out what appellants and adjudicators may do after a decision, dismissal, or remand is issued. Some examples of post adjudication actions include: effectuating a final decision, updating the administrative record, correcting clerical errors, re-openings, requests to vacate dismissal, remands and other matters. Previously, the OCPM did not fully discuss all of the post-adjudication options the way the updated version does.

Revised chapters 5, 6, 7, and 19 became effective on July 27, 2018. These chapters contain the same general content, but OMHA significantly modified the organization of the chapters. The structure of the chapters went from a list of rules with brief explanations to a comprehensive question and answer approach. These organizational shifts show how OMHA is trying to make the OCPM easier to read and understand.

The OCPM is an essential resource for both appellants and adjudicators to navigate the Medicare appeals process. Wachler & Associates highly recommends that appellants familiarize themselves with the OCPM, as it provides important information about participating in the appeals process, Through the reorganized content and more detailed guidance for both appellants and adjudicators, the revised OCPM should improve efficiencies in the Medicare appeals process.

Wachler & Associates will continue to stay up to date with changes to the OCPM and other current healthcare topics.  We have the expertise and the dedication to aid you or your healthcare provider in appealing a Medicare claim audit. Furthermore, if you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at (248) 544-0888, or via email at wapc@wachler.com. You may also subscribe to our health law blog by adding your email at the top right of this page.