Other Fields
Agency Scheme: 
HHSOOHAI0003
ADJUDICATION STRUCTURE
Hearing Level: Basic Structure
Name of Hearing Office (local name): 
Office of Hearings and Inquiries
Name of Hearing Office (global name): 
Department of Health and Human Services: Office of Hearings and Inquiries
Hearing Officer #1 (Title): 
CMS Hearing Officers
Are administrative appeals permitted from final decisions at the hearing-level stage?: 
Yes (Some Types of Cases)
Comments/Notes on Adjudication Structure: 

Besides housing the Board Members and support staff for the independent statutory Boards (Medicare Geographic Classification Review Board (MGCRB) and Provider Reimbursement Review Board (PRRB)) the CMS Office of Hearings conducts a wide variety of adversarial institutional appeals under the CMS Hearing Officer/Reviewing Official/Presiding Officer functions. There are currently 5 active docket of cases for first level hearings: Medicare Advantage/Prescription Drug Plan Contract Denials and terminations (42 CFR 422.641, 42 CFR 423.641-698); Retiree Drug Subsidy Determinations (42 CFR 423.890); Medicaid State Plan Amendment Determinations (42 CFR 430.60-430.104); HMO cost reimbursement appeals (42 C.F.R. ยง 417.576(d)(4)); and Risk Adjustment Data Validation Appeals (42 CFR 422.311). Hearing Decisions may be reviewed/appealed to the CMS Administrator. Additionally, OH conducts second level Organ Procurement Organization (OPO) cost reimbursement appeals (42 CFR 405.1834--2nd level appeal) from which there is no administrative review.

For State Plan Amendment cases, judicial review (To Court of Appeals) is available after OH's Recommended Decision is reviewed/appealed at the CMS Administrator level.

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?: 
Either
About what percentage of private parties were represented at hearings (FY2013)?: 
95.00%
Is the agency permitted to have representation at hearings?: 
Yes (All Types of Cases)
Who may serve as an agency representative?: 
Either
Regulations/rules of practice for hearings (please include CFR citations): 
See Part I, Section2
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 for the Medicaid State Plan Amendment cases pursuant to 42 CFR 430.86
Does the hearing officer have subpoena authority?: 
No
Are ex parte contacts prohibited?: 
Yes (All Types of Cases)
Are parties provided notice of hearing?: 
Yes (All Types of Cases)
PROCESS & PROCEDURE - Hearing Procedure
What types of hearings are permitted at the hearing-level stage?: 
Written (Document-Only) Hearing
In-Person
Phone
Please provide the approximate percentage of each type of hearing relative to the total number of hearings (FY2013)
Written (Document-Only) Hearing: 
40%
In-Person: 
20%
Phone: 
20%
How is the type of hearing selected: 
By Agency
By Private Party
Please describe: 
For State Plan Amendment cases, States have the right to a hearing conducted in its assigned CMS Regional Office. For other cases, factors such as whether factual or legal issues are disputed, the amount in controversy and case complexity are discussed and considered at a pre hearing conference for the hearing officer and parties to evaluate the forum type most appropriate and efficient. For Risk Adjustment Data Validation appeals, the hearing officer has full discretion whether to grant a live or telephonic hearing.
How many hearing officers preside at each hearing?: 
Varies by Case
If "Varies by Case," please describe: 
Hearing officer(s) preside solo or as a panel.
Is witness testimony permitted at hearings?: 
Varies by Case
If "Varies by Case," please describe: 
OPO cost report cases. which review lower level Medicare Contractor hearing officer decisions, are conducted on the record. The controlling regulations for Retiree Drug Subsidy cases provide for the right to a hearing date but do not permit the hearing officer to receive testimony. Risk Adjustment Data Validation appeals indicate that subject to the hearing officers discretion, a live or telephonic hearing may be conducted but no testimony may be received. Witnesses may testify in HMO Cost Report. Medicaid State Plan Amendment and Medicare Advantage Prescription Drug Plan Contract Determination cases.
Can parties cross-examine witnesses?: 
Varies by Case
If "Varies by Case," please describe: 
Witnesses who testify in hearing officer cases are subject to cross examination. This question is not applicable to document-only hearings.
Can third-parties submit amicus briefs and/or evidence?: 
Adjudication Officer Discretion
Are hearings recorded and/or transcribed?: 
Yes
Are hearings open to the public?: 
Varies by Case
If "Varies by Case," please describe: 
As a general rule CMS Office of Hearings cases are open. Individuals may petition to file Amicus briefs for State Plan Amendment pursuant to 42 CFR 430.80.
PROCESS & PROCEDURE - Post-Hearing Procedure
Who typically drafts the decision at the hearing-level stage?: 
Adjudication Officer
Who has authority to issue final decisions?: 
Adjudication Officer
Program Official
If "Other," please specify: 
In Medicaid State Plan Amendment appeals, the Hearing Officer issues a recommended decision for the CMS Administrator's review. The Administrator issues the final decision. For the remaining appeals listed in Part I, Section 2, the Hearing Officer's decision is final unless reviewed by or appealed to the CMS Administrator.
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): 
For Medicare Advantage/Prescription Drug Plan cases, pursuant to 42 CFR 422.660(c) and 423.650(c), decisions favorable to organizations must be issued by September 1 for the contract in question to be effective for the following calendar year.
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: 
The CMS Office of Hearings performs initial in-take procedures on each case as it is received. In general, briefing schedules and hearing dates are set depending on the complexity of issues and requests of the parties. Hearings in Medicare Advantage/Prescription Drug Plan contract appeals are managed to accommodate the contract period of performance as referenced above in Part II, Section 4. Depending on nature of case, time to adjudicate cases varies.
Does the agency permit web-based electronic filing of hearing-related briefs or other documents?: 
No
Are final decisions 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: 
Medicare Advantage/ Prescription Drug Plan contract determination cases are currently published 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): 
Please see Part I, Section 2.
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): 
Please see Part I, Section 2.
ADJUDICATORS
Total # of Hearing Officers: 
4
ADR: General Information
Is ADR available at one or more points during the hearing process?: 
Yes
If "Yes," when is ADR available?: 
Pre-Hearing
Is ADR a mandatory or voluntary process?: 
Voluntary
What type(s) of ADR are available?: 
Mediation
Who conducts the ADR?: 
Other
If "Other," please specify:: 
OH staffer trained in mediation who is not involved in case may conduct confidential mediation.
Comments/Notes on ADR Process (Optional): 
ADR is not prohibited by regulation or statute. Currently, for the first time, there is a hearing officer case which is being mediated. In recent years, the CMS Hearing Office has suggested voluntary mediation for particular cases but consent of both parties was not obtained.
CASELOAD STATISTICS - Summary Statistics
Total # Cases Filed/Opened (FY2013): 
16
Total # Cases Decided/Closed (FY2013): 
15
Total # Cases Pending (End of FY2013): 
2
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
Verified by Agency: 
Verified