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office of medicare hearings and appeals

The Department of Health and Human Services (HHS) has committed to improving the Medicare claims appeals process. This commitment includes the internal implementation of an expanded Settlement Conference Facilitation (SCF) program by the Office of Medicare Hearings and Appeals (OMHA). SCF is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals.


In order to educate all Medicare Part A and Medicare Part B providers and suppliers who have OMHA or Medicare Appeals Council appeals pending, an SCF Expansion Open Door Call will be held on Tuesday, May 22, 2018 at 1:30 pm. The call will focus on the logistics of the SCF process and SCF eligibility criteria. Providers that plan to join the call are encouraged to submit their questions in advance via email and include “SCF May 22 Call” in the subject line. To participate, registration is required. Additionally, providers are encouraged to read the updated SCF expansion materials, including an SCF Expansion Frequently Asked Questions document, on the website.

On Thursday, June 29, 2017, the Centers for Medicare and Medicaid Services (CMS) and the Office of Medicare Hearings and Appeals (OMHA) will host a call from 1:00 pm to 3:00 pm that will focus on the recent regulatory changes to the Medicare claims appeals process. There will also be discussion surrounding the Medicare Appeals Final Rule that was published in the January 17, 2017 Federal Register, as well as the changes that are intended to streamline the administrative appeals processes, reduce the backlog of pending appeals, and increase the consistency in decision making across appeal levels.

To participate in the call, registration is required by 12:00 pm on June 29, or until the event is full. Following the presentation, time will be allocated to a session for questions and answers.

In an effort to reduce the large backlog of Medicare coverage and payment appeals, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would revise the procedures the Department of Health and Human Services (HHS) would follow at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations. This proposed rule covers items and services provided to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, the proposed rule would revise procedures that HHS would follow at CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level. As of April 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of the current fiscal year. The proposed rule includes provisions to expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The proposed rule was published in the July 5, 2016 Federal Register. Comments are due by Monday, August 29, 2016.

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In late February, the Office of Medicare Hearings and Appeals (OMHA) announced an expansion (Phase III) of its Settlement Conference Facilitation pilot to include Medicare Part A claims, which includes claims under dispute from Inpatient Rehabilitation Facilities. This announcement was part of an Appellant Forum hosted by OMHA. The agenda and slide presentation from the forum provide additional information.

OMHA is the entity that is responsible for administering the Administrative Law Judge (ALJ) level of the Medicare appeals process. This expansion, which became effective on February 25, 2016, is an effort to help resolve the extensive backlog of ALJ hearing requests, which is approximately at 240,000 for FY 2015. The previous phases of expansion were limited to Part B claims and have been in effect since June of 2014. To date, only a small amount of claims have been removed from the queue.