CMS Pub. 100-06, ch. 6, § 360.3

B3-13410.3

Section B is intended for all requests for ALJ hearings including those expected to be dismissed

for failure to meet the $500 amount in controversy requirement or for any other reason (such as a

lack of a fair hearing).

The carrier counts ALJ Hearings in Columns 1 and 2 using the following two methodologies:

Column (1) Total - The total of all ALJ hearing requests as originally filed.

Column (2) Dispositions - For lines 49 and 51-53 only, the carrier reports the number of

dispositions rendered by the ALJ(s) in cases reported as cleared for the month in Line 49. There

will usually be more ALJ dispositions than cases counted in line 49. A case is not counted in line

49 until the ALJ has cleared all of the claims included in the request for hearing.

EXAMPLE: The carrier forwards one request to an ALJ involving 20 claims. The ALJ

dismisses 10 claims at once. A month later, the ALJ decides to affirm the original

decision on 5 others as one group. The other 5 receive separate determinations.

This is counted as 7 dispositions.

Line 40. Opening Pending - The number of ALJ hearings reported on line 57 as closing pending

on the previous month's report.

Line 41. Adjustments to Pending - If line 42 of the current month differs from data in line 57 of

the previous month, there must be an entry in line 41 for the current month. The carrier precedes

the entry by a "+" or "-", as appropriate. See definition for line 2.

Line 42. Adjusted Opening Pending - The result of line 40 + line 41 (taking into account the "-"

sign, if any).

Line 43. Requests Received - The number of ALJ hearings requested during the month. (See The

Medicare Claims Processing Manual, Chapter 30, Beneficiary Correspondence and Appeals.)

Line 44. Requests Forwarded to ALJ - The number of ALJ hearing requests forwarded to ALJs

during the month. The carrier considers the case forwarded when all necessary material has been

mailed to the ALJ.

Line 45. No. of Claims Involved - The number of claims involved in the ALJ hearing requests

forwarded to ALJs as reported on line 44. (See MCM-3, §§3000-3000.2 for definition of claim.)

Line 46. No. Forwarded in 1-7 Days - The number of ALJ hearing requests forwarded to ALJs

within 7 calendar days from receipt of the request to mailing of the necessary information. The

carrier shows data for all cases mailed during the month. The number must be less than, or equal

to, the number shown in line 44.

Line 47. No. Forwarded in 1-14 Days - The number of ALJ hearing requests forwarded to ALJs

within 14 days from receipt of the request to mailing of the necessary information. The carrier

shows data for all cases mailed during the month. The number must be less than, or equal to, the

number shown in line 44.

Line 48. Average Time to Forward - The average number of calendar days from receipt of the

ALJ request to the mailing date of the necessary information. The carrier the same methodology

for counting as discussed in §360.2 for line 13.

Line 49. ALJ Hearings Completed - The number of ALJ hearing requests completed during the

month. The carrier considers a case completed when it receives the completed decision from the

ALJ for all parts of the case.

Line 50. Amount in Controversy - For ALJ hearings reported as affirmed (line 51) or reversed

(line 53), during the month, the carrier shows the total dollar amount remaining in controversy

according to the initial ALJ hearing request. This should be the amount remaining after previous

appeal decisions. (See The Medicare Claims Processing Manual, Chapter 30, Beneficiary

Correspondence and Appeals on how to determine the amount in controversy.) It rounds results

to the nearest dollar.

Line 51. Affirmations - The carrier reports number of completed ALJ hearings in which the

previous determination was completely upheld i.e., no change was made. All parts of all claims in

a case must be upheld in order for the case to be counted as an affirmation. See line 53 for partial

affirmations. (The carrier does not include partial affirmations on this line.)

If the prior determination is upheld, but payment is made under limitation of liability, the carrier

counts the ALJ hearing determination as an affirmation. It reports the appropriate information in

lines 55 and 56.

Line 52. Dismissals/Withdrawals - The e number of completed ALJ hearings that were

withdrawn by the appellant or dismissed (before determination) by the ALJ. The carrier reports an

appeal that was requested and withdrawn or dismissed within the same month here and in lines 43,

44, and 49.

Line 53. Reversals (Full or Part) - The total number of completed ALJ hearings in which at least

part of the prior determination was reversed i.e., a change was made and some or all of the new

determination was in favor of the appellant. For example, if an ALJ hearing involves several

claims, and the initial determinations for some of the claims are affirmed and some are reversed,

the carrier considers the decision a reversal.

Line 54. Amount Awarded - For cases included in line 53, the carrier shows the amount of

allowed charges for services where the determination was reversed. It shows charges after

reasonable charge reductions, but prior to application of deductible and coinsurance amounts. (If

the appeal involved a reasonable charge reduction, it shows the additional amount allowed.) It

rounds results to the nearest dollar.

Line 55. Waived - Ben. and Prov - The number of claims involved in requests for ALJ hearings

where limitation of liability was granted to both the beneficiary and provider in an assigned claim

(see The Medicare Claims Processing Manual, Chapter X, Limitation on Liability), or where the

provider's liability was limited in an unassigned claim(see 3 The Medicare Claims Processing

Manual, Chapter X, Limitation on Liability).

Line 56. Amount Awarded - For cases included in line 55, the carrier shows the amount of

allowed charges for services (including the noncovered services) where the liability of the

beneficiary and provider were limited. It shows charges after reasonable charge reductions, but

prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.

Line 57. Closing Pending - The total number of ALJ hearing requests that were not completed by

the end of the reporting month. The carrier considers a case transferred to an ALJ as pending until

it has received the complete decision from the ALJ for all parts of the case.

Line 58. Effectuation of ALJ Decisions - The number of ALJ hearing decisions for which it

initiated effectuation during the month. The carrier considers effectuation of a decision to be

initiated when it completes the following:

• Submission of claim to CWF if payment can be made without further development; or

• Initiation of development e.g., when it must ascertain whether or not the provider has

refunded payment to the beneficiary.

Line 59. Number 1-7 Days - The number of cases where the carrier effectuated the decision

within 7 days, inclusive, of receipt of the decision in its corporate mailroom.

Line 60. Number 8-15 Days - The number of cases where the carrier effectuated the decision

within 8-15 days, inclusive, of receipt of the decision in its corporate mailroom.

Line 61. Number 16-30 Days - The number of cases where the carrier effectuated the decision

within 16-30 days, inclusive, of receipt of the decision in its corporate mailroom.

Line 62. Number Over 30 Days - The number of cases where the carrier effectuated the decision

in more than 30 days, inclusive, of receipt of the decision in its corporate mailroom.