Background - (Rev. 4, 07-18-03)

7500 - Background - (Rev. 4, 07-18-03) The Office of Hearings and Appeals (OHA) of the Social Security Administration (SSA) conducts hearings. Beneficiaries may appeal any medical necessity or appropriateness of setting determination made by you to an Administrative Law Judge (ALJ) where there is at least $200 or more at issue (See 42 CFR 478.40). Beneficiaries also may appeal your limitation on liability determination (Title XVIII, §1879 of the Act) where $100 or more is at issue. Providers and practitioners may only appeal to an ALJ your waiver on liability determination where $100 or more is at issue (if the beneficiary does not request an ALJ hearing on that same issue). That is, they can only appeal the issue of whether they knew or should have known that care or services were covered by Medicare. Providers and practitioners cannot request an appeal about the issue of medical necessity or appropriateness of setting under Title XI, §1155 of the Act. Providers can appeal your circumvention of PPS denial determinations under §1886(f)(2) of the Act where $100 or more is at issue (See §1869(b)(2)(A) of the Act and 42 CFR 405.720(d)). There are no appeal rights to DRG changes beyond DRG re-review. NOTE: Once a request for hearing is filed (even if the above rules do not appear to be met), only OHA can dismiss the case. Therefore, process and forward every request for hearing to OHA within 30 calendar days from the date of receipt of the request.