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SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals

HALLEX
Volume I

Transmittal No. I-5-5-5

Division 5: Temporary Instructions

Subject: Medicare Claims Processing

Background

Increases in the size and scope of the Medicare appeals workload have generated numerous requests from hearing offices for updated processing instructions. This issuance is the product of a collaborative effort between the Office of Hearings and Appeals and the Health Care Financing Administration to improve the identification, routing and effectuation of Administrative Law Judge (ALJ) and Appeals Council (AC) actions in Medicare cases.

Explanation of Content and Changes

This issuance contains definitions of commonly used Medicare terms and applicable case control codes. It explains the three types of case control numbers used for Medicare cases and when they are used. It sets forth the statutory authorities for appeals of Medicare claims and discusses who may appeal and who should be a party to various types of appeals. It discusses who may act as a representative and representative fees. This temporary instruction also contains copies of new Request for Hearing forms for Medicare, new decision and dismissal headings, new routing forms and revised cover letters for Medicare decisions and dismissals. It also discusses the routing and distribution of files and copies.

Managers should furnish copies of this TI to all hearing office (HO) and Headquarters personnel responsible for processing Medicare cases.

Remove

These instructions supersede all previously existing instructions for the areas addressed. The following are now obsolete and must be removed:

  • Interim Circular (IC) 154 (HALLEX TI 5-501)

  • IC 171 and 171, Supplement A (HALLEX TI 5-103)

  • Chief ALJ Reminder Item routing instructions issued May 15, 1989

  • any prior routing instructions issued by the Part B Medicare Development Center (DC).

Insert

Insert in binder for Volume I, Division 5 (Temporary Instructions), in numerical order after 5-504.

Date: April 19, 1991