Part A and Part B ALJ Hearings

100.4 – Section C – Part A and Part B ALJ Hearings (Rev. 45, 05-28-04) Use Section C to report requests for ALJ hearings, including those expected to be dismissed for failure to meet the amount in controversy requirement or for any other reason, such as the lack of a fair hearing in Part B cases. ALJ HEARINGS FALL INTO THE FOLLOWING CATEGORIES: Column (1) TOTAL.--All Part A ALJ hearing requests as originally filed. Column 1 must equal the sum of columns 2, 3 and 4. Column (2) SNF.--All skilled nursing facility (SNF) hearings. Column (3) HHA/HOSPICE.--All home health agency (HHA) and hospice hearings. Column (4) OTHER.--All other hearings. Column (5) PART B.--All Part B ALJ hearings. Line 52. Opening Pending.--Show the number of ALJ hearings reported on Line 67 as the closing pending on the previous month's report. Line 53. Adjustments to Pending.--See definition for line 2. If line 54 of the current month differs from data in line 67 of the previous month, there must be an entry in line 53 for the current month. Precede the entry by a "+" or "-" as appropriate. Line 54. Adjusted Pending.--Show the result of line 52 + line 53 (taking into account the "-" sign, if any). Line 55. Requests Received.--Show the number of ALJ hearings requested during the month. (See §3797) Line 56. Requests Forwarded to ALJ.--Show the number of ALJ hearing requests forwarded to ALJs during the month. Consider the case forwarded when all necessary material has been mailed to the ALJ. Line 57. No. of Claims Involved.--Show the number of claims involved in the ALJ hearing requests forwarded to ALJs as reported on line 56. Line 58. In 1-7 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs within 7 calendar days from receipt of the request in the corporate mailroom to mailing of the necessary information. Show data for all cases mailed during the month. The number must be less than, or equal to, the number shown in line 56. Line 59. In 1-14 Calendar Days.--Show the number of ALJ hearing requests forwarded to ALJs within 14 calendar days from receipt of the request in the corporate mailroom to mailing of the necessary information to the ALJ. Show data for all cases mailed during the month. Note that the number in this line must be less than or equal to the number shown in line 56. Line 60. Average Time to Forward.--Report the average number of calendar days from receipt of the ALJ request to the date of mailing of the necessary information. Use the methodology discussed in §3888.2 for line 13. Line 61. Completed.--Show the number of ALJ hearing requests completed during the month. Consider a case completed when you have received the completed decision from the ALJ for all parts of the case. Line 62. Amount in Controversy.--For ALJ hearings reported as affirmed (line 63) or reversed (line 65), during the month, show the total dollar amount in controversy according to the initial ALJ hearing request. This should be the amount remaining after previous appeals decisions. Round results to the nearest dollar. Line 63. Affirmations.--Show the number of completed ALJ hearings in which the previous determination was completely upheld, i.e., no change was made. All parts of all claims in a case must be upheld in order for the case to be counted as an affirmation. See line 65 for partial affirmations. (Do not include partial affirmations on this line.) If the prior determination was upheld, but payment was made under limitation of liability, count the ALJ hearing determination as an affirmation. Report the appropriate information in lines 77 and 78. Line 64. Dismissals/Withdrawals.--Show the number of completed hearings that were withdrawn by the appellant or dismissed (before determination) by the ALJ. Report an appeal that was requested and withdrawn or dismissed within the same month here and in lines 55, 56, and 61. Line 65. Reversals (Full or Part).--Show the total number of completed ALJ hearings in which at least part of the prior determination was reversed; i.e., a change was made and some or all of the new determination was in favor of the appellant. For example, if an ALJ hearing involved several claims, and the initial determinations for some were affirmed and some were reversed, consider the decision to be a reversal. Line 66. Amount Awarded.--For cases included in line 65, show the amount of submitted charges for services where the determination was reversed. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar. Line 67. Closing Pending.--Show the total number of ALJ hearing requests that were not completed by the end of the reporting month. Consider a case transferred to an ALJ as pending until you have received the completed decision from the ALJ for all parts of the case. ALJ DISPOSITIONS Line 68. Number of Dispositions.--Report the number of dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 61. There will usually be more ALJ dispositions than cases counted in line 61. Do not count a case in line 61 until the ALJ has cleared all of the claims included in the request for hearing. EXAMPLE: You forwarded one request to an ALJ involving 20 claims. The ALJ dismisses 10 claims at once. A month later, the ALJ decides to affirm the original decision on 5 others as one group. The other five claims receive separate determinations. This would be counted as seven dispositions. Line 69. Affirmations.--Of those dispositions shown in line 68, report the number of decisions rendered by the ALJ(s) that were completely upheld. Line 70. Dismissals/Withdrawals.--Of those dispositions shown in line 68, report the number of dismissals and withdrawals issued by the ALJ(s). Line 71. Reversals.--Of those dispositions shown in line 68, report the number of decisions rendered by the ALJ (s) in which at least part of the prior determination was reversed. EFFECTUATION OF ALJ DECISIONS Line 72. Total Effectuations.--Show the number of ALJ hearing decisions for which you initiated effectuation during the month. Consider effectuation of a decision to be initiated when you: o Submit the claim to CWF if payment can be made without further development; or o Initiate development, e.g., when you must determine whether or not the provider has refunded payment to the beneficiary. Line 73. Number 1-7 Days.--Show the number of cases where you effectuated the decision within 7 days. Effectuation days include day of receipt of the decision in your corporate mailroom. Line 74. Number 8-15 Days.--Show the number of cases where you effectuated the decision within 8-15 days. Line 75. Number 16-30 Days.--Show the number of cases where you effectuated the decision within 16-30 days. Line 76. Number Over 30 Days.--Show the number of cases where you effectuated the decision in more than 30 days. LIMITATION OF LIABILITY DETERMINATION IN ALJ CASES Line 77. No. Waived - Ben. and Prov..--Show the number of claims in ALJ hearings during the reporting month where the liability of both the beneficiary and provider was limited. Line 78. Amount Awarded.--For claims included in line 77, show the amount of the submitted charges for services where the liability was limited (including non-covered services where the liability of the beneficiary and provider are limited.) Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.