Other Fields
Agency Scheme: 
HHSOOBEN0001
Level: 
Appeal Level One
ADJUDICATION STRUCTURE
Appeals: Basic Structure
Appeal Office (local name): 
Departmental Appeals Board Medicare Appeals Council
Appeal Office (global name): 
Department of Health and Human Services: Departmental Appeals Board Medicare Appeals Council
Sub-Agency/Bureau/Division:: 
Medicare Operations Division
Appeal Officer #1 (Title): 
Administrative Appeals Judge
Appeal Officer #2 (Title): 
Appeals Officer
Are administrative appeals permitted from final decisions issued by this appellate office?: 
No
Comments/Notes on Adjudication Structure: 
The name “Departmental Appeals Board” is used to refer to two entities: (1) the decision-making body consisting of Board Members, appointed by the Secretary, who issue decisions made by panels of three Board Members; and (2) the larger organization, located within the Office of the Secretary, which includes the Board, Administrative Law Judges (ALJs), Administrative Appeals Judges who serve on the Medicare Appeals Council, and organizational divisions that support the judges and other administrative functions. The term “Board” is used to refer to the decision-making body and the acronym “DAB” to refer to the larger organization. HHS administers healthcare insurance benefits under the Medicare Program. There are four distinct health insurance programs within the Medicare program and each has its own appeals process. These health insurance programs are referred to as "parts." Only certain parts of the programs benefits are adjudicated. Claimants appeal adverse initial determinations to the Office of Medicare Hearings and Appeals (OMHA). However, OMHA is only responsible for Level 3 of the Medicare claims appeal process and certain Medicare entitlement appeals and Part B premium appeals. OMHA Administrative Law Judges hear these cases and claimants may appeal adverse decisions to the DAB's Medicare Appeals Council (Council). The Medicare Operations Division provides staff support to the Administrative Appeals Judges and Appeals Officers on the Council. The Council provides the final administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment filed by beneficiaries or health care providers/suppliers.
PROCESS & PROCEDURE - General Information
Which party (or parties) is/are permitted to file appeals with this office?: 
Private Party
Are private parties permitted to have representation at appeal hearings?: 
Yes (All Types of Cases)
Who may serve as a private party representative?: 
Either
Is the agency permitted to have representation at appeal hearings?: 
N/A (e.g., Agency Not Party to Hearing)
Are ex parte contacts prohibited?: 
Yes (All Types of Cases)
Regulations/rules of practice for appeal hearings (please include CFR citations): 
42 CFR Part 405
Other published guidance for appeal hearings (if any): 
http://www.hhs.gov/dab/divisions/medicareoperations/index.html http://www.hhs.gov/dab/divisions/medicareoperations/medicare_appeals-procedures.html http://www.hhs.gov/dab/divisions/medicareoperations/reconsiderationqic.html http://www.hhs.gov/dab/divisions/medicareoperations/dismissalqic.html http://www.hhs.gov/dab/divisions/medicareoperations/undecided.html
PROCESS & PROCEDURE - Hearing Procedure
What types of hearings are permitted on appeals adjudicated by this office?: 
Written (Document-Only) Hearing
In-Person
Video
Please provide the approximate percentage of each type of hearing relative to the total number of appeal hearings (FY2013)
Written (Document-Only) Hearing: 
100%
How is the type of hearing selected for appeals heard by this office?: 
Depends on Nature of Case/Claim
If "Depends on Nature of Case/Claim", please describe: 
A party may request an oral argument. The Council will grant a request for oral argument if it decides that the case raises an important question of law, policy or fact that cannot be readily decided based on the written submissions. See 42 CFR 405.1124.
How many appeal officers preside at each hearing?: 
Four or More
Is factual development permitted at the appellate hearing as a means of supplementing the record from below?: 
Yes (Some Types of Cases)
Can third-parties submit amicus briefs and/or evidence?: 
No
Are appeal hearings recorded and/or transcribed?: 
Yes
N/A (Document-Only Hearings)
Are appeal hearings open to the public?: 
Varies by Case
If "Varies by Case," please describe: 
Hearings are always closed. This question is not applicable to document-only hearings.
PROCESS & PROCEDURE - Post-Hearing Procedure
Who typically drafts final decisions on appellate cases adjudicated by this office?: 
Adjudication Officer
Staff Attorney
Who has authority to issue final decisions on appellate cases adjudicated by this office?: 
Adjudication Officer
Do agency regulations or guidance provide time limits for issuance of final decisions on appellate cases?: 
Yes (All Types of Cases)
If "Yes," please specify these time limit(s): 
When the Council reviews an ALJ's decision, the Council must issue a final decision or dismissal order or remands a case to the ALJ within 90 days of the receipt of the request for review. 42 CFR 405.1100(c). If the appeal is escalated from the ALJ level to the Council, the Council will issue a final decision or dismissal order or remand a case to the ALJ within 180 days of the receipt of the request for escalation. 42 CFR 405.1100(d).
About how long does it take on average—as of FY2013—to adjudicate appeals by this office?: 
214 Days
Is judicial review available after issuance of a final decision on appellate cases adjudicated by this office?: 
Yes (All Types of Cases)
PROCESS & PROCEDURE - Case Management
How are claims/cases processed at this appellate office?: 
Other
Please briefly describe your case management practice(s) at this office: 
Due to the number of pending appeals with the Council and increased requests for review, the Council gives priority to beneficiary appeals.
Does the agency permit web-based electronic filing of briefs or other documents in cases adjudicated by this appellate office?: 
No
Are final decisions issued by this appellate office published and/or posted on the agency website?: 
Yes (Some Decisions)
If "Yes (Some Decisions)," how does the agency determine which final decisions to publish/post? Please briefly describe: 
The Council publishes its decisions online at, http://www.hhs.gov/dab/divisions/medicareoperations/macdecisions/mac_decisions.html.
Do agency regulations/rules of practice specify the contents of the administrative record on appeals heard by this office?: 
No
Do agency regulations/rules of practice provide for closure of the record on appeals heard by this office?: 
No
PROCESS & PROCEDURE
Comments/Notes on Appellate Process & Procedures (Optional): 
Regarding agency representation at appeal hearings, note that regulations permit CMS or its contractors to be party to a hearing. See 42 CFR 405.1012.
ADJUDICATORS
Total # of Appeal Officers: 
4
Comments/Notes on Appellate Adjudicators (Optional): 
The Council is comprised of 4 Administrative Appeals Judges. Currently, the Chair has re-delegated certain authorities delegated by the HHS Secretary under the Social Security Act, to 5 Appeals Officers.
ADR: General Information
Is ADR available at one or more points for appellate cases heard by this office?: 
Yes
If "Yes," when is ADR available?: 
Pre-Hearing
Post-Hearing
Is ADR a mandatory or voluntary process?: 
Voluntary
What type(s) of ADR are available?: 
Mediation
If "Other," please specify:: 
http://www.hhs.gov/dab/divisions/adr/index.html
Who conducts the ADR?: 
Third-Party Neutral
Regulations/rules of practice governing ADR process (please include CFR citations): 
http://www.hhs.gov/dab/divisions/adr/standards/standards.html
Other published guidance on ADR process (if any):: 
http://www.hhs.gov/dab/divisions/adr/mediation/process.html
CASELOAD STATISTICS - Summary Statistics
Total # Cases Filed/Opened (FY2013): 
4,277
Total # Cases Decided/Closed (FY2013): 
2,591
Total # Cases Pending (End of FY2013): 
4,637
CASELOAD STATISTICS - Supplementary Statistics
Does your agency maintain annual caseload statistics for this hearing office by case type (e.g., discrimination complaint, licen: 
Yes
If "Yes," please indicate preferred format below.: 
By providing case type statistics on this form
WRAP-UP
Are there distinctive or innovative features of the appellate-level adjudication program covered on this form that you wish to: 
The Departmental Appeals Board began a pilot program with Medicare contractors to receive claim files electronically in cases in which CMS seeks own motion review (agency referrals). The DAB hopes to expand the use of electronic records to other types of cases, eventually moving to e-records in all cases.
Setting aside budgetary or legislative constraints (if any), does your agency have a "wish list" of processes or procedures (e.g: 
See above.
Verified by Agency: 
Verified