Medicare Financial Management Manual (Pub. 100-06), Ch. 6 § 100.3

Part B Hearing Results

Last amended: 2004Year: 2004Length: 803 wordsOfficial source
100.3 – Section B – Part B Hearing Results (Rev. 45, 05-28-04) Section B deals with data on Part B hearings completed during the month. Base data shown on actual counts of each activity and not derived from sampling or other estimating techniques. HEARINGS FALL INTO THE FOLLOWING CATEGORIES: Column (1) On-the-Record with No Subsequent Hearing.--Include in column 1 hearings held where the appellant originally requested an OTR hearing, indicates that he/she is satisfied with the OTR decision, that he/she wishes to proceed with an ALJ hearing (if the amount in controversy is $500 or more), or fails to respond to the OTR within the required time frame. In addition, if the appellant requests an in-person or telephone hearing subsequent to an OTR decision, but the hearing is dismissed or withdrawn, include it here and not in columns (2) or (3). Column (2) All Telephone.--Include in column 2, hearings where the appellant requested and had a telephone hearing subsequent to an OTR hearing decision, or a telephone hearing was held without a prior OTR decision. Count all telephone hearings including those where the appellant did not follow-up timely to the OTR notice, but later requested a telephone hearing. Column (3) All In-Person.--Include in column 3 hearings where the appellant requested and had an in-person hearing subsequent to an OTR hearing decision, or an in- person hearing was held without a prior OTR decision. Count all in-person hearings including those where the appellant did not follow-up timely to the OTR notice but later requested an in-person hearing. Column (4) Number in 120 Days.--For the total cases included in line 47, columns 2 and 3, (e.g., the sum) show for lines 49-51 the numbers that were completed within 120 days of receipt. Use the methodology shown above the explanation for line 13 to determine the completion date. Where an OTR decision is made and the appellant chooses to not follow-up timely and later requests either an in- person or telephone hearing, completion time for this second reported hearing is measured from the date of receipt of original request to the date of the second decision. If the appellant does not appear, dismiss the hearing in accordance with §3794.3k, and use the date of notice of dismissal as your date completed. Line 45. Reversals.--Under the appropriate columns, show the number of OTR, telephone, and in- person hearings completed in the month in which at least part of the review determination was reversed i.e., a change was made and some, or all, of the new determination was in favor of the appellant. (See the definition for line 11.) Line 46. Affirmations.--Under the appropriate columns, show the number of OTR, telephone, and in-person hearings completed in the month in which the review determination was completely upheld, i.e., no change was made. All parts of all claims must be upheld in order for the case to be counted as an affirmation. (See the definition for line 9.) Line 47. Total Decisions.--Show the total number of hearing decisions completed during the month that resulted in a reversal or affirmation, excluding dismissals and withdrawals. Line 48. Number in 120 Days.--For cases included in line 47, show the number that were completed within 120 days of receipt. See methodology for column 4 to determine the completion date. Line 49. No Previous OTR Held.--For cases included in line 47, columns (2) and (3), report the number where you held the telephone or in-person hearing without first making an OTR decision, i.e., the OTR hearing was bypassed. In column (4), report the number of cases included in either column (2) or (3) which were completed within 120 days. Line 50. Previous OTR Counted.--For the cases included in line 47, columns (2) and (3), report the number where you included the OTR count on a previous report. In column (4), report the number of cases included in either column (2) or (3) that were completed within 120 days. Cases reported in line 50 are those where an OTR decision was made and the appellant either accepted the OTR decision, did not respond timely, or decided to go directly from the OTR decision to an ALJ hearing. Then, subsequent to this OTR decision "acceptance," the appellant changed his/her mind and decided that he/she wanted a telephone or in-person hearing. Do not include these cases in line 6. Line 51. Previous OTR Not Counted.--For cases included in line 47, columns (2) and (3), report the number where you did not include the OTR count on a previous report. These are cases where you made the OTR decision first, and the appellant indicated in a timely fashion (see §3794.9) that he/she wanted a telephone or in-person hearing. In column (4), report the number of cases included in either column (2) or (3) that were completed within 120 days.
Medicare Financial Management Manual (Pub. 100-06), Ch. 6 § 100.3: Part B Hearing Results | Justis AI