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.
