DI 45005: Processing Reconsideration, Hearings, and Appeals Medicare ESRD Cases
ALJ’s in SSA’s OHO have jurisdiction for hearings requested on adverse ESRD Medicare entitlement determinations — denials, cessation, and onset. The FO is the control point for obtaining and associating the folder with the request for hearing and forwarding all pertinent material to the appropriate hearing office where the case will be assigned to an ALJ. General guidelines for hearings cases pertinent to ESRD Medicare claims may be found in DI 11052.045.
SSA’s OHO is under certain time constraints to issue hearing decisions. These time limits are measured from the date the request for hearing is filed. Therefore, all actions taken on the case prior to forwarding it to OHO should be expedited and flagged for priority handling.
The ODO reconsideration examiner, in preparing the ESRD and any related monthly benefit claims folders for referral to the hearing office, via the FO, should ascertain whether there is new evidence, or clear indications in the old evidence, showing that the reconsideration determination was incorrect. If so, and a totally favorable action is now possible, reopen the reconsideration determination being guided by the basic procedures in DI 45001.001 or DI 45010.001, as well as in DI 45005.001. In proceeding with a favorable (revised) determination, also take the following action:
Send two copies of the notice or award certificate to the ALJ and a copy to the DO.
If in reviewing the folders for referral to the ALJ, via the DO, equivocal medical evidence is found which might likely be resolved (by CMS"s Medical Officer for ESRD via telephone discussion with the treating source, et. al.) totally in favor of the appellant, refer the folder first (with all material) requesting priority handling, to CMS, BERC, OEP, DMEP, Medicare Entitlement Branch, Room 349 East High Rise under cover of an SSA-559. These cases should be routed to CMS via OD, SPB, 3-M-25 Operations Building.
Show in Remarks: “ESRD Hearing Request. Please provide medical review. If the reconsideration determination should be reopened and revised to an allowance (or continuance), return the folder to (designate the Mod component) reconsideration examiner. Otherwise, forward the folder to the appropriate field office and notify ODO Case Control of the new folder location. Do not hold case for more than 60 days.” If the reconsideration determination was clearly an appropriate denial or cessation, ODO will forward the folder directly to the district office.
Once a favorable hearings or appeals decision is rendered, the claim file should be returned to ODO for effectuation and processing. The reconsideration examiner is responsible for all aspects of the determination, although advice and/or nonmedical decisions and forms preparations may be obtained as required from authorizers, earnings reviewers, etc. Follow the guidelines in sections DI 45001.025, DI 45005.001, and DI 45010.001, modifying the SSA-892-U3, notices, etc. to reflect the correct level of appeal.
If the file contains unclear or irreconcilable conflicts, ODO should forward the claim on a high priority, e.g., special messenger, basis to CMS via OD, SPB, 3-M-25 Operations Building.