CMS Pub. 100-06, ch. 3, § 200.7.4

Decisions.

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

A. Fully and Partially Favorable Decisions:

1. Upon receipt of the Administrative QIC effectuation notice, contractors shall have

30 calendar days to calculate and refund the 935 interest to the provider.

• Calculate and create a manual invoice in HIGLAS to refund the 935 interest

• This calculation begins from the finalized claim adjustment date or the receipt

date of the extrapolated recalculation to the entry date of the manual invoice.

• Shall calculate and refund the 935 interest from the final claim adjustment date

in accordance with 42 CFR § 405.378.

Note: On Partially Favorable calculations, if the decision by the ALJ, Medicare

Appeals Council, Federal district court or a subsequent Federal reviewing court,

reverses the overpayment determination, as modified by prior levels of administrative

or judicial review, in part, the Medicare contractor in effectuating the decision may

allocate recouped monies to that part of the overpayment determination affirmed by the

decision. Interest will be paid to the provider or supplier on recouped amounts that

remain after this allocation in accordance with paragraph (j) in 42 CFR §405.378.

2. Contractors should review the ALJ, and subsequent levels Notice of decision to

ensure all dates agree with the Administrative QIC Effectuation Notice and/or in the

MAS.

D. Extrapolated overpayments with a Favorable Decisions:

• Contractors shall have an additional 15 calendar days (a total of 45 calendar

days) for all extrapolation overpayments to calculate and refund 935 interest to

the provider.

E. Line by Line (Claims with multiple lines of services) Partially Favorable Decision:

• Contractors shall have an additional 15 calendar days (a total of 45 calendar

days) when the decision is on individual line/s to calculate and refund 935 interest

to the provider.

Note: Office of Medicare Hearings and Appeals (OMHA) has developed a system similar

to MAS called Electronic Case Adjudication and Processing Environment (ECAPE).

Due to system limitations, OMHA made changes to the decision letters and processes

related to the decision date.

a. On/after May 2018, OMHA’s decision letters no longer include a date of

decision, only the wet signature of the ALJ.

b. The ‘decision date’ is captured in the Notice of Decision.

c. The date captured in the Notice of Decision will match the date captured in

MAS.

For purposes of calculating interest for 935 Overpayments, contractors utilizing MAS

shall use the date captured in the Notice of Decision for OMHA decisions after May 2018.

Website Information

The OMHA ALJ Appeal Status Information System serves to allow appellants to check

the status of appeals submitted to OMHA.

https://www.hhs.gov/about/agencies/omha/filing-an-appeal/appeals-status-

lookup/index.html

https://www.hhs.gov/about/agencies/omha/index.