CMS Pub. 100-04, ch. 29, § 330.4

In most cases, OMHA will: (1) issue a decision based on the request for an ALJ hearing or

review; or (2) issue an order of dismissal of the appellant’s request for ALJ hearing or review;

or (3) remand the case to the QIC.

If OMHA’s decision is partially or wholly favorable to the appellant and gives a specific

amount to be paid, the MAC effectuates within 30 calendar days of receipt of the effectuation

notice from the AdQIC. The MAC must acknowledge receipt of the AdQIC effectuation per

the JOA with the AdQIC.

If the decision is partially or wholly favorable but the amount must be computed by the

MAC, it effectuates the decision within 30 days after it computes the amount to be paid to

the appellant. The amount must be computed as soon as possible, but no later than within

30 calendar days of the date of receipt of the effectuation notice from the AdQIC.

For effectuation of decisions that involve overpayments or underpayments where the

limitation on recoupment provision applies (Section 935 of MMA), refer to IOM Pub. 100-

06, Chapter 3, §200 for further instruction.

If clarification from the AdQIC is necessary, the MAC considers the date of the clarification

the final determination for purposes of effectuation. If clarification is needed from the

provider/physician/supplier (e.g., splitting charges), the MAC requests clarification as soon as

possible and computes the amount payable within 30 calendar days after the receipt of the

necessary clarification. The MAC considers the date of receipt of the clarification as the date

of the final determination for purposes of effectuation.