Review and Effectuation of OMHA Decisions

330.3 - Review and Effectuation of OMHA Decisions (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) The Administrative QIC (AdQIC) is the clearinghouse for all Original Medicare (Part A and Part B) claim case files and decisions from the OMHA field offices as well as any decisions and case files from the Appeals Council. The AdQIC reviews OMHA decisions for possible agency referral to the Appeals Council. For Appeals Council decisions and for OMHA decisions when no agency referral is planned, the AdQIC will send the MAC an effectuation notice, a copy of the decision, and a summary of the associated claims from the MAS. The MAC only effectuates based on documentation received from the AdQIC; the MAC does not effectuate based on correspondence from any party to the ALJ hearing or attorney adjudicator review. "Effectuate" means for the MAC to issue a payment or change liability. In the event that the MAC’s claims payment review finds the OMHA or Appeals Council decision to be inconsistent or inaccurate in comparison to claims history the MAC may request assistance from the AdQIC in seeking clarification from OMHA or the Appeals Council.