CMS Pub. 100-06, ch. 3, § 200.5

Level of Appeals

(Rev. 12509; Isuued:02-15-24; Effective: 07-01-24; Implementation: 07-01-24)

Whether or not the provider subsequently appeals the overpayment to the ALJ,

Departmental of Appeals Board (DAB), or Federal court, contractors shall continue to

recoup until the debt is satisfied in full. Recoupment remains in effect as provided in

CFR 42 §405.373 (e). Refer to Publication 100-04, Medicare Claims Processing Manual,

Chapter 29 §330-330.2. If an overpayment determination subject to the limitation

on recoupment under 42 CFR §§ 405.379 and 405.378 is reversed in whole or in part on

funds recouped (excluding voluntary payments, ERS collections, and immediate

recoupments requested by the provider or supplier prior to the Qualified Independent

Contractor decision), the 935 interest shall be paid to the provider or supplier.

A. Glossary:

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 when 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.

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.”

Effectuate - This means for the MAC to issue a payment or change liability.

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.

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.

Administrative Law Judge (ALJ) - Adjudicator employed by the Department of Health

& Human Services (HHS), Office of Medicare Hearings and Appeals (OMHA) that holds

hearings and issues decisions related to level 3 of the appeals process.

Department of Appeals Board (DAB) Review - The DAB provides an impartial,

independent review of disputed decisions in a wide range of Department of Health and

Human Services programs under more than 60 statutory provisions.

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.

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.

Note: For additional information go to Publication 100.04, Medicare Claims

Processing Manual Chapter 29 - Appeals of Claims Decisions