OMHA Receipts for Fiscal Year 2011-2013

$0 / year

This dataset provides information about the appeals and claims received by the Office of Medicare and Hearings by appeal category for Fiscal Year 2011-2013. This dataset is provided by the U.S. Department of Health & Human Services. It includes the information regarding appeals and claims by the Office of Medicare Hearings and Appeals (OMHA).

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OMHA administers the nationwide Administrative Law Judge (ALJ) hearing program for appeals arising from individual claims for Medicare coverage and payment for items and services furnished to beneficiaries (or enrollees) under Medicare Parts A, B, C and D. OMHA also hears appeals arising from claims for entitlement to Medicare benefits and disputes of Part B and Part D premium surcharges. OMHA generally conducts the third level of a five-level appeals process, and operates separately from the other agencies involved in the Medicare claims appeal process.

OMHA is responsible for Level 3 of the Medicare claims appeal process; certain Medicare entitlement appeals; Part B and Part D premium appeals. It was created by the Medicare Modernization Act of 2003 to simplify the appeals process and make it more efficient. During an appeal, an OMHA Administrative Law Judge or attorney adjudicator conducts a new (“de novo”) review of an appellant’s case and issues a decision based on the facts and the law.

The Chief Administrative Law Judge leads the entire agency, which consists of six field offices and a headquarters office. Each field office includes many Administrative Law Judges and attorney adjudicators who are overseen by an Associate Chief Administrative Law Judge. Appeals are assigned to these adjudicators by a Centralized Docketing Division in accordance with standardized procedures.

The entry point of the appeals process depends on the part of the Medicare program that covers the disputed benefit or whether the beneficiary is enrolled in a Medicare Advantage plan. Within OMHA, which is responsible for Level 3 claims appeals, if an individual disagrees with the Level 2 decision or dismissal, the individual may request that an OMHA adjudicator review the action.

This dataset includes ALJ Number, Appeal Category, Request and Requestor Type, Record Type and Date, Appeal Status, Hearing Type and much more.

Date Created

2016-08-22

Last Modified

2016-08-22

Version

2016-08-22

Update Frequency

Annual

Temporal Coverage

2011-2013

Spatial Coverage

United States

Source

John Snow Labs => U.S. Department of Health & Human Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Appeals, Claims, Medicare, Office of Medicare Hearings and Appeals (OMHA)

Other Titles

Office of Medicare Hearings and Appeals Receipts for 2011-2013, Appeals and Claims Received by OMHA for Fiscal Year 2011-2013, 2011-2013 Appeals and Claims Receipts by OMHA

Name Description Type Constraints
Fiscal_YearIt refers to the Fiscal Year of the date the request was completed.daterequired : 1
Administrative_Law_Judge_NumberIt includes the System generated unique number identifying the appeal.stringrequired : 1
ClaimsThe number of claims with a disposition record associated with the appeal.string-
Record_DateRefers to he date the request was completed.daterequired : 1
Request_TypeIt the type of request received for the appeal.stringenum : Array
Appeal_CategoryIt includes the classification of the services in the claim.stringrequired : 1
Medicare_PartIt includes the high level Medicare part grouping by part letter derived from Medicare appeal type values.stringrequired : 1 enum : Array
Requestor_TypeIt Identifies the type of party that requested the appeal.stringenum : Array
StateFull name of different states of U.S.string-
State_CodeThe state Code from the personal address of the primary appellant associated to the appeal.string-
Is_On_The_RecordIt indicates if an Administrative Law Judge (ALJ) appeal has been through an On-the-Record decision process.booleanrequired : 1 enum : Array
Is_Program_Safeguard_Contractor_Or_Zone_Program_Integrity_ContractorIt identifies a Program Safeguard Contractor (PSC) Or Zone Program Integrity Contractor (ZPIC).booleanrequired : 1 enum : Array
Is_Recovery_Audit_ContractorIt identifies a Recovery Audit Contractor (RAC).booleanrequired : 1 enum : Array
Hearing_Completed_DateIt identifies the date that the hearing was completed.date-
Is_Hearing_TypeIt represents the type of hearing.booleanrequired : 1 enum : Array
Hearing_FormatIt represents the format of hearing that actually occurred for the hearing on the appeal.stringenum : Array
Decision_Letter_Mailed_DateIt includes the date of the appellant is sent (mailed) the decision letter. This field will be the appeal stop date and used to calculate the timeliness of most types of appeals.date-
DispositionIt includes the derived field that stores the logical roll up of dispositions to an appeal.stringrequired : 1 enum : Array
Appeal_StatusIt includes the current status in the process of adjudicating an appeal (Open, Closed, Assigned, Reopened, etc).stringrequired : 1 enum : Array
Procedure_CodeIt includes the Code used to codify some aspect of the claim line item.string-
Procedure_DescriptionIt includes the description of the code used to describe the CLI code provided on a claim line item.string-
Fiscal_YearAdministrative_Law_Judge_NumberClaimsRecord_DateRequest_TypeAppeal_CategoryMedicare_PartRequestor_TypeStateState_CodeIs_On_The_RecordIs_Program_Safeguard_Contractor_Or_Zone_Program_Integrity_ContractorIs_Recovery_Audit_ContractorHearing_Completed_DateIs_Hearing_TypeHearing_FormatDecision_Letter_Mailed_DateDispositionAppeal_StatusProcedure_CodeProcedure_Description
20121-93761273112012-03-26MailOtherPart BFamilyfalsefalsefalsefalseNo DispositionPending
20121-115180564122012-09-24MailOtherPart BOhioOHfalsefalsefalsefalseNo DispositionPending
20121-9299444872012-03-12MailOtherPart BProviderfalsefalsefalsefalseNo DispositionPending
20121-9807044912012-05-14MailOtherPart AProviderfalsefalsefalsefalseNo DispositionPending
20121-9897583752012-05-18MailOtherPart BProviderfalsefalsefalsefalseNo DispositionPending
20121-9897591802012-05-18MailOtherPart BProviderfalsefalsefalsefalseNo DispositionPending
20111-76445322812011-04-08MailOtherPart AProviderfalsetruefalsefalseNo DispositionCombined
20111-76452446212011-04-08MailOtherPart AProviderfalsetruefalsefalseNo DispositionCombined
20111-76651808112011-04-15MailOtherPart AProviderfalsetruefalsefalseNo DispositionCombined
20111-78082582512011-05-06MailOtherPart BProviderfalsefalsefalsefalseNo DispositionPending
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