OMHA Announces Delays in Processing Appeals of Part A, Part B Claims Denials

The Office of Medicare Hearings and Appeals (“OMHA”) has announced a significant delay in its time frames for processing appeals of claims denials under Medicare Part A and Part B.

OMHA is the office within the U. S. Department of Health and Human Services that is responsible for processing Medicare claims appeals at the Administrative Law Judge level. Specifically, and following processing/consideration of a claim by, first, the relevant Medicare Administrative Contractor and, second, a Qualified Independent Contractor, an OMHA Administrative Law Judge conducts a new (“de novo”) review of an appellant’s claim and issues a decision based on the facts and the law. OMHA was created by the Medicare Modernization Act of 2003, for the purpose of simplifying the appeals process and making it more efficient.

Citing an “overwhelming number of receipts and the existing workload within the Agency,” OMHA has made two announcements. First, for appeals filed after July 15, 2013, OMHA expects that assigning these appeals to ALJs will be delayed 10 to 12 months.

Second, OMHA expects that even docketing appeals into its system — which must occur before OMHA assigns appeals to ALJs — will be delayed 8 to 12 weeks.

There are multiple uncertainties in OMHA’s announcements. For example, it is unclear whether the delays are culumulative, i. e., whether the 10 to 12 month delay in assigning appeals to ALJs includes the 8 to 12 week delay in docketing appeals into OMHA’s system. It also is unclear whether the 8 to 12 week delay in docketing appeals applies only to appeals filed after July 15, 2013, or to all pending appeals.

As part of its announcements, OMHA said that it will continue to process Part D prescription drug denial cases that qualify for expedited status within 10 days. It also said that it will screen all incoming requests to ensure that appeals filed by beneficiaries are prioritized, given that these appeals “often present emergent circumstances that must be promptly addressed.”

Appellants have certain escalation rights to skip the ALJ level and to move their cases directly to the next level of appeal, before the Medicare Appeals Council. OMHA referenced these rights in making its announcements.

OMHA’s announcements are available on its website:

Please contact us if you would like to discuss the potential effects of OMHA’s announcements, as well as what may be appropriate ways of proceeding.

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