Other Fields
Agency Scheme: 
Hearing Level: Basic Structure
Name of Hearing Office (local name): 
Office of Medicare Hearings and Appeals
Name of Hearing Office (global name): 
Department of Health and Human Services: Office of Medicare Hearings and Appeals
Hearing Officer #1 (Title): 
Administrative Law Judge
Are administrative appeals permitted from final decisions at the hearing-level stage?: 
Yes (All Types of Cases)
Comments/Notes on Adjudication Structure: 

Medicare beneficiaries, providers, suppliers, and Medicaid State Agencies (collectively referred to as "parties" or "appellants") may appeal adverse benefit claim determinations to the Office of Medicare Hearings and Appeals (OMHA). However, the Office of Medicare Hearings and Appeals is only responsible for the third of four levels of administrative appeal for most determinations related to items or service furnished to Medicare beneficiaries, and the second of three levels of administrative review for determinations related to a provider discharge, and beneficiary appeals of entitlement or eligibility to the Medicare program, Part B premium late enrollment penalties, and income-related adjustments to premiums -- because most appeals relate to appeal of items or services furnished to beneficiaries, OMHA is generally referred to as the Level 3 appeal. ALJs hear these cases and parties may appeal adverse ALJ decisions to the Departmental Appeals Board's Medicare Appeals Council. Attorney advisors are authorized to recommend fully favorable decisions on the paper record, but ALJs retain exclusive authority to issue the binding decisions. In addition, ALJs review "Level 2" dismissals -- no hearing is required, and decisions affirming a dismissal may not be appealed.

PROCESS & PROCEDURE - General Information
Are private parties permitted to have representation at hearings?: 
Yes (All Types of Cases)
Who may serve as a private party representative?: 
About what percentage of private parties were represented at hearings (FY2013)?: 
Is the agency permitted to have representation at hearings?: 
Yes (All Types of Cases)
Who may serve as an agency representative?: 
Regulations/rules of practice for hearings (please include CFR citations): 
42 CFR 405 subpart I; part 422 subpart M; part 423 subpart U; part 478 subpart B
PROCESS & PROCEDURE - Pre-Hearing Procedure
Is discovery permitted by either party at the hearing-level stage?: 
Yes (Some Types of Cases)
Briefly describe the scope and type(s) of discovery available (e.g., depositions, interrogatories, etc.): 
Discovery is permitted if CMS or a CMS contractor elects party status in the appeal -- see 42 CFR 405.1037. Under Part 405 adjudications, CMS and CMS contractors may not elect party status if the appellant is an unrepresented beneficiary. Under Part 422 adjudications, the application of the 405 discovery rule is unclear -- the managed care plan (a type of CMS contractor) has party status pursuant to the statute. In Part 423 adjudications, CMS and CMS contractors are not permitted to take party status -- their role is limited to "participant" status, thus no discovery is permitted. Discovery can include limited depositions, interrogatories and document requests are allowed.
Does the hearing officer have subpoena authority?: 
Yes (All Types of Cases)
Are ex parte contacts prohibited?: 
Yes (All Types of Cases)
Are parties provided notice of hearing?: 
Yes (All Types of Cases)
How far in advance of the hearing date is notice typically provided?: 
20 Days
PROCESS & PROCEDURE - Hearing Procedure
What types of hearings are permitted at the hearing-level stage?: 
Written (Document-Only) Hearing
Please provide the approximate percentage of each type of hearing relative to the total number of hearings (FY2013)
Written (Document-Only) Hearing: 
How is the type of hearing selected: 
By Agency
By Private Party
Required by Rule
Depends on Nature of Case/Claim
Please describe: 
If VTC technology is available, the rules make that default mode of hearing. If VTC technology is not available or special/extraordinary circumstances exist, the rules state that an in-person hearing should be conducted -- appellants may request an in-person hearing and assert special/extraordinary circumstances exist, and the ALJ may grant the request if the ALJ agrees that special/extraordinary circumstances exist. A telephone hearing is also an available option for appellants and others participating in the hearing. See 42 CFR 405.1020.
How many hearing officers preside at each hearing?: 
Is witness testimony permitted at hearings?: 
Varies by Case
If "Varies by Case," please describe: 
Witness testimony is permitted in oral hearings (in-person, video, or telephone). This question is not applicable to document-only hearings.
Can parties cross-examine witnesses?: 
Varies by Case
If "Varies by Case," please describe: 
Cross-examination is permitted in oral hearings (in-person, video, or telephone). This question is not applicable to document-only hearings.
Can third-parties submit amicus briefs and/or evidence?: 
Are hearings recorded and/or transcribed?: 
Are 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 the decision at the hearing-level stage?: 
Staff Attorney
Who has authority to issue final decisions?: 
Adjudication Officer
Do agency regulations or guidance provide time limits for issuance of final decisions?: 
Yes (Some Types of Cases)
If "Yes," please specify these time limit(s): 
Most Medicare Parts A and B appeals have a 90-day time frame by statute, and may be escalated to the next level of appeal if the time frame is not met (at the election of the appealing party). If an appeal is escalated from "Level 2," the time frame is 180 days. Medicare Part D appeals have a 90-day standard time frame and a 10-day expedited time frame (if expedited criteria met) by regulation (escalation is not an option in these cases). For other appeals (Part A and Part B appeals of decisions from QIOs and SSA; Part C appeals), there is no established time frame.
About how long does it take on average—as of FY2013—to adjudicate claims/cases at the hearinglevel stage (i.e., from case filing: 
221 Days
Is judicial review available after issuance of a final decision?: 
Yes (Some Types of Cases)
PROCESS & PROCEDURE - Case Management
How are claims/cases processed at the hearing-level stage?: 
Differentiated Case Management
Please briefly describe your case management practice(s) at the hearing level stage: 
Beneficiary-initiated appeals are prioritized and processed as received. All other appeals are processed FIFO.
Does the agency permit web-based electronic filing of hearing-related briefs or other documents?: 
Are final decisions published and/or posted on the agency website?: 
Do agency regulations/rules of practice specify the contents of the administrative record at the hearing-level stage?: 
Yes (All Types of Cases)
If "Yes," please provide citation(s): 
42 CFR 405.1042; 423.2042
Do agency regulations/rules of practice provide for closure of the record at the hearing-level stage (subject to applicable exce: 
Yes (All Types of Cases)
If "Yes," please provide citation(s): 
The record is closed so far as the basis of the ALJ's decision -- this is not explicit, but is true as a practical matter. There are then limtied opportunities for the consideration of new evidence at the Appeals COuncil level -- see 42 CFR 405.1122, or for the purpose of reopneing the ALJ's decision -- see 42 CFR 405.986, which allows new and material evidence to establish good cause for reopening a decision within the constraints of 405.980.
Comments/Notes on Hearing-Level Process & Procedures (Optional): 
The Office of Medicare Hearings and Appeals (OMHA) is responsible for administering the ALJ hearing level (commonly referred to as Level 3) of the Medicare claims appeal process, and certain Medicare entitlement appeals and Part B and Part D premium appeals. OMHA was established in 2005, in response to the MMA of 2003, which required the transfer of the Medicare ALJ hearing function from SSA to HHS, and together with the BIPA of 2000, simplified and expanded access to the appeals process. During an appeal, an OMHA ALJ conducts a new ("de novo") review of an appellant's case and issues a decision based on the facts and the law. The Chief Administrative Law Judge leads the entire agency, which consists of five field offices and a headquarters office. Each field office includes many Administrative Law Judges who are overseen by an Associate Chief Administrative Law Judge. Appeals are assigned to these Administrative Law Judges by a Centralized Docketing Division in accordance with standardized procedures.
Total # of Hearing Officers: 
ADR: General Information
Is ADR available at one or more points during the hearing process?: 
CASELOAD STATISTICS - Summary Statistics
Total # Cases Filed/Opened (FY2013): 
384 151
Total # Cases Decided/Closed (FY2013): 
79 377
Total # Cases Pending (End of FY2013): 
240 116
CASELOAD STATISTICS - Supplementary Statistics
Does your agency maintain annual caseload statistics for this hearing office by case type (e.g., discrimination complaint, licen: 
If "Yes," please indicate preferred format below.: 
By providing case type statistics on this form
Do you have any additional comments about your agency's responses on this form? If so, please provide comments below.: 
While the Office of Medicare Hearings and Appeals only adjudicates Medicare claims, the claims are for different parts of Medicare Coverage. Thus, in reply to the request to supply supplemental statistics, the Medicare Part distribution is provided.
Setting aside budgetary or legislative constraints (if any), does your agency have a "wish list" of processes or procedures (e.g: 
OMHA has initial funding for an electronic record that allows submission of appeals on-line, allows appellants to view the record on-line, and allows ALJs to adjudicate from the electronic record. One challenge will be the coordination of data exchange with CMS. As CMS explores new review processes and methodologies, coordination with OMHA and the Departmental Appeals Board is a necessity for impact analysis, budget planning, and to avoid future backlogs and ensure sufficient resources.
Verified by Agency: