Overview of the Appeals Demonstration
On Jan.1, 2016, CMS launched the QIC Telephone Discussion and Reopening Process Demonstration to test whether further engagement between Durable Medical Equipment (DME) suppliers and the DME QIC would improve the understanding of the cause of appeal denials and, over time, result in more proper claim submission at the DME MAC level from suppliers participating in the Demonstration. The Demonstration initially focused on oxygen and glucose/diabetic testing strip supplies. However, since initial implementation, CMS further expanded the Demonstration activities to include all DME claim types within DME MAC Jurisdictions A, B, C, and D, with exception to claims or suppliers that were already subject to another Centers for Medicare & Medicaid Services (CMS) initiative (e.g., Prior Authorization for Power Mobility Devices (PMDs), Settlement Conference Facilitation (SCF)) and for claims for glucose/diabetic testing strip supplies submitted within DME MAC Jurisdictions A and B. Effective May 1, 2019, CMS is further expanding the Demonstration activities to the Part A East (PAE) QIC jurisdiction. Under the expanded Demonstration, the PAE QIC shall offer telephone discussions and/or reopenings to providers within MAC Jurisdictions H, J, K, L, M, and N, and home health and hospice (HHH) related appeals within MAC Jurisdictions J6 and J15. Reconsiderations for service termination, hospital discharge reviews and claims or providers that are already involved in another CMS initiative (e.g. SCF) are not eligible for telephone discussions and/or reopenings under the Demonstration.
Under the Demonstration, selected provider/suppliers have the opportunity to participate in a recorded telephone discussion that will be included and considered as part of the appeals case file, prior to C2C’s reconsideration decision. Participation in the Telephone Discussion Demonstration is voluntary.
Upon receipt of a valid reconsideration request, the QIC shall identify cases/claims that would benefit from the telephone discussion process under this Demonstration. Between two and six weeks of receipt of an appeal, providers/suppliers may receive an invitation to participate. C2C will issue a form letter notifying the appellant that the claim has been selected to participate in the Telephone Discussion Demonstration. Participants will be allowed 14 calendar days from the date of the notification letter to respond by returning the forms with the enclosed letter and indicate a desire whether or not participate in this voluntary Telephone Discussion Demonstration.
If the providers/supplier concurs with the request to participate in the Telephone Discussion Demonstration, C2C will conduct the telephone discussions and shall be specific in clarifying Medicare policies and requirements, educating the providers/suppliers, and identifying any materials, evidence, and/or documentation that would yield a favorable outcome as part of the reconsideration process. Following the telephone discussion, a reconsideration professional at the QIC will conduct the medical or technical review, considering and applying any additional information or supporting documentation that was provided as a result of the telephone discussion. After reviewing all documentation available, the reconsideration professional will issue a decision on the case.
In addition to the telephone discussions, the DME and PAE QICs also conduct analysis on previously completed unfavorable reconsideration decisions dated on or after Jan. 1, 2013, to identify potential appeals that can now be resolved favorably through the reopenings process. Under this Demonstration, the QIC has the authority to conduct reopenings on previously adjudicated unfavorable claims that are currently pending Administrative Law Judge (ALJ) assignment at the Office of Medicare Hearings and Appeals (OMHA), and/or unfavorable reconsiderations that have been decided by the QIC, but not yet appealed to OMHA. Further, the QIC assists providers/suppliers in submitting withdrawal requests to OMHA when, through the course of the Demonstration activities, the provider/supplier decides to discontinue pursuing appeal(s) currently pending at OMHA.
Access more information on the PAE Demonstration activities.