CMS Pub. 100-04, ch. 29, § 110

Adjudicator – The entity responsible for making the decision at any level of the Medicare claim

decision making process, from initial determination to the final level of appeal, on a specific claim.

Administrative Law Judge (ALJ) – Adjudicator employed by the Department of Health and Human

Services (HHS), Office of Medicare Hearings and Appeals (OMHA) that holds hearings and issues

decisions related to level 3 of the appeals process.

Affirmation - A term used to denote that a prior claims determination has been upheld by the current

claims adjudicator. Although appeals through the OMHA level are de novo, CMS and its contractors

often use this term when an adjudicator reaches the same conclusion as that in the prior determination,

even though he/she is not bound by the prior determination.

Amount in Controversy (AIC) - The dollar amount required to be in dispute to establish the right to a

particular level of appeal. Congress establishes the amount in controversy requirements.

Appeals Council – The Medicare Appeals Council (herein Appeals Council), a division within the

Departmental Appeals Board, provides the final level of administrative review of claims for entitlement

to Medicare and individual claims for Medicare coverage and payment. (See also Departmental Appeals

Board.)

Appellant - The term used to designate the party (i.e., the beneficiary, provider, supplier, or other person

showing an interest in the claim determination) or the representative of the party that has filed an appeal.

The adjudicator determines if a particular appellant is a proper party or representative of a proper party.

Applicable plan – Applicable plan means liability insurance (including self-insurance), no-fault

insurance, or a workers' compensation law or plan.

Appointed representative – The individual appointed by a party to represent the party in a Medicare

claim or claim appeal.

Assignee – (1) With respect to the assignment of a claim for items or services, the assignee is the

supplier who has furnished items or services to a beneficiary and has accepted a valid assignment of a

claim;

OR

(2) With respect to an assignment of appeal rights, an assignee is a provider or supplier who is not

already a party to an appeal, who has furnished items or services to a beneficiary, and has accepted a

valid assignment of the right to appeal a claim executed by the beneficiary.

Assignment of appeal rights – The transfer by a beneficiary of his or her right to appeal under the

claims appeal process to a provider or supplier who is not already a party, and who provided the items or

services to the beneficiary.

Assignor – A beneficiary whose provider of service or supplier has taken assignment of a claim, or

assignment of an appeal of a claim.

Attorney Adjudicator - A licensed attorney employed by OMHA with knowledge of Medicare

coverage and payment laws and guidance, authorized to take the actions provided for in 42 CFR 405

subpart I on requests for ALJ hearing and requests for reviews of QIC dismissals.

Authorized representative – An individual authorized under State or other applicable law to act on

behalf of a beneficiary or other party involved in the appeal. The authorized representative will have all

of the rights and responsibilities of a beneficiary or party, as applicable, throughout the appeals process.

Beneficiary – Individual who is enrolled to receive benefits under Medicare Part A and/or Part B.

Contractor - An entity that contracts with the Federal government to review and/or adjudicate claims,

determinations and/or decisions.

Date of Receipt – A determination, decision or notice is presumed to have been received by the party

five days from the date included on the determination or decision, unless there is evidence to the

contrary.

NOTE: Throughout Chapter 29, reference to day or days means calendar days unless otherwise

specified.

Departmental Appeals Board (DAB) Review - The DAB provides impartial, independent review of

disputed decisions in a wide range of Department of Health and Human Services programs under more

than 60 statutory provisions. The Medicare Appeals Council (herein Appeals Council), a division within

the Departmental Appeals Board, provides the final level of administrative review of claims for

entitlement to Medicare and individual claims for Medicare coverage and payment. (See section 340 in

this chapter.)

De Novo - Latin phrase meaning “anew” or “afresh,” used to denote the manner in which claims are

adjudicated in the administrative appeals process. Adjudicators at each level of appeal make a new,

independent and thorough evaluation of the claim(s) at issue, and are not bound by the findings and

decision made by an adjudicator in a prior determination or decision.

Decisions and Determinations -If a Medicare appeal request does not result in a dismissal, adjudication

of the appeal results in either a “determination” or “decision.” There is no apparent practical distinction

between these two terms although applicable regulations use the terms in distinct contexts.

A decision that is reopened and thereafter revised is called a “revised determination.”

Dismissal - An action taken by an adjudicator when an appeal will not be conducted as requested. A

request for appeal may be dismissed for any number of reasons, including:

1. Abandonment of the appeal by the appellant;

2. A request is made by the appellant to withdraw the appeal;

3. A determination that an appellant is not a proper party;

4. The amount in controversy requirements have not been met; and

5. The appellant has died and no one else is prejudiced by the claims determination.

Limitation on Liability Determination- Section 1879 of the Social Security Act (the Act) provides

financial relief to beneficiaries, providers and suppliers by permitting Medicare payment to be made, or

requiring refunds to be made, for certain services and items for which Medicare coverage and payment

would otherwise be denied. This section of the Act is referred to as “the limitation on liability

provision.” Both the underlying coverage determination and the limitation on liability determination

may be challenged. For more detailed information see chapter 30 of this manual.

Medicare number and/or Medicare beneficiary identifier (Mbi) - are general terms describing a

beneficiary’s Medicare identification number. Medicare beneficiary identifier references both the Health

Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new

Medicare card transition period and after for certain business areas that will continue to use the HICN as

part of their processes. For the beneficiary population, the term Medicare number is used to describe the

Medicare beneficiary identifier (Mbi).

Office of Medicare Hearings and Appeals (OMHA) - The Office of Medicare Hearings and Appeals

is responsible for level 3 of the Medicare claims appeal process and certain Medicare entitlement

appeals and Part B premium appeals. At level 3 of the appeals process, an appellant may have a hearing

before an OMHA ALJ, or review by an attorney adjudicator.

Party - A person and/or entity normally understood to have standing to appeal an initial determination

and/or a subsequent administrative appeal determination or decision. (See section 210 in this chapter.)

Provider of services (herein provider) – As used in this section, the definition in 42 CFR 405.902 for

provider applies. Provider means a hospital, a critical access hospital (CAH), a skilled nursing facility, a

comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an

agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that

has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology

services, or a community mental health center that has in effect a similar agreement but only to furnish

partial hospitalization or intensive outpatient services. NOTE: A non-participating provider, that is, an

entity eligible to enter into a provider agreement to participate in Medicare but has not entered into such

an agreement, is not considered a provider of services and does not have party status for an initial

determination or appeal.

Qualified Independent Contractor (QIC) – Entity that contracts with the Secretary in accordance with

the Act to perform level 2 appeals, which are called reconsiderations, and expedited reconsiderations.

Remand – An action taken by an adjudicator to vacate a lower level appeal decision, or a portion of the

decision, and return the case, or a portion of the case, to that level for a new decision.

Reopening - See IOM 100-04 Chapter 34.

Reversal - Although appeals in the administrative appeals process are de novo proceedings (i.e., a new

determination/decision is made at each level), Medicare uses this term where the new

determination/decision is more favorable to the appellant than the prior determination/decision, even if

some aspects of the prior determination/decision remain the same.

NOTE: The term reversal describes the coverage determination, not the liability determination. For

example, an item or service may be determined to be non-covered as not medically reasonable and

necessary (under section 1862(a)(1)(A) of the Act), but Medicare may, nevertheless, make payment for

the item or service if the party is found not financially liable after applying the limitation on liability

provision (section 1879 of the Act). Thus, the coverage determination is affirmed, but Medicare makes

payment as required by statute.

Revised Determination or Decision - An initial determination or decision that is reopened and which

results in the issuance of a revised determination or decision. A revised determination or decision is

considered a separate and distinct determination or decision and may be appealed. For example, a

postpayment review of an initial determination that results in a reversal of a previously covered/paid

claim (and, potentially, a subsequent overpayment determination) constitutes a reopening and a revised

initial determination. The first level of appeal following a revised initial determination is a

redetermination. Spouse - The word “spouse” as used in this chapter, and as used in sections 405.952,

405.972, 405.1052, and 405.1114 of title 42 of the Code of Federal Regulations (CFR) regarding the

dismissal of an appeal includes same-sex spouses as well as opposite-sex spouses. The relationship of

two individuals of the same sex will be recognized as a marriage if either (1) the state or territory in

which the individuals live recognizes their relationship as a marriage, or (2) the individuals entered into

a legally valid marriage under the law of any state, territory, or foreign jurisdiction. Because civil unions

and domestic partnerships are not marriages, civil union and domestic partners are not regarded as

spouses by CMS.

Supplier –Unless the context otherwise requires, a physician or other practitioner, a facility, or entity

(other than a provider of services) that furnishes items or services under Medicare.

Vacate – To set aside a previous action.