GN 03101.150:
Medicare Entitlement Appeals
Effective Dates: 02/04/2015 - Present- Effective Dates: 12/08/2017 - Present
- TN 11 (08-08)
- GN 03101.150 Medicare Entitlement Appeals
- A. Policy – Medicare Entitlement Appeals
- 1. Reconsiderations
- All reconsiderations concerning Medicare entitlement (Part A hospital insurance or Part B supplementary medical insurance) are the responsibility of SSA.
- 2. Hearings
- a. Non-medical issues
- Administrative law judge (ALJ) hearings on all Medicare entitlement issues (except for disability determinations) are the responsibility of Health and Human Services (HHS). SSA takes ALJ requests on Medicare entitlement claims for HHS, and forwards these requests to the HHS Office of Medicare Hearings and Appeals’ (OMHA) Centralized Docketing. See GN 03108.210 for more information.
- b. Medical issues
Hearings on disability determinations related to Medicare entitlement for Medicare Qualified Government Employee (MQGE) claims under Sections 210(p) and 226(b)(2)(C) of the Social Security Act are the responsibility of the SSA Office of Disability Adjudication and Review (ODAR).- Hearings on disability determinations related to Medicare entitlement for Medicare Qualified Government Employee (MQGE) claims under Sections 210(p) and 226(b)(2)(C) of the Social Security Act are the responsibility of the SSA Office of Hearings and Operations (OHO).
- 3. Appeals Council (AC)
- The HHS AC reviews decisions made by HHS ALJ’s, and the SSA AC reviews decisions made by SSA ALJ’s.
- NOTE: Appeals involving reimbursement of Medicare claims are handled by Qualified Independent Contractors and the HHS OMHA. See Title XVIII Medicare Fee-For-Service Appeals, GN 03108.200.
- B. Policy - Special Situations
- 1. Office of Disability Operations (ODO)
- ODO reconsiders initial Part A and Part B entitlement determinations on domestic end stage renal disease (ESRD) claims. For jurisdiction if the claimant's spouse has filed, see Priority of Jurisdiction-Two Processing Centers Involved, GN 01050.060.
- 2. Railroad Retirement Board (RRB)
- RRB is responsible for Part A and Part B entitlement determinations for, and appeals by, qualified RRB annuitants (QRRB's) who are not entitled to Social Security benefits. If the QRRB is entitled to Social Security benefits, SSA processes the appeal through its regular appeals process.
3. Office of Disability Adjudication and Review (ODAR)- 3. OHO and the Office Analytics, Review, and Oversight, Office of Appellate Operations (OAO)
ODAR is responsible for hearings and Requests for AC Review on disability determinations related to Medicare entitlement for MQGE claims.- OHO is responsible for hearings and OAO is responsible for Appeals Council review requests.
- C. Reference
- GN 04040.040 - Relationship Between Equitable Relief and Administrative Finality
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