FAQs Related to the DME Telephone Discussion Demonstration
Q. What should I do if my mailing address has changed since I mailed in my Reconsideration?
A. Please email us your new address and a contact telephone number in case we have any questions to DMEPDFeedback@c2cinc.com.
Q. Why did CMS initially limit the telephone discussions to include only oxygen and glucose?
A. Oxygen and diabetic testing supplies claims were selected because they make up a large portion of appeals submitted for second level review. Due to this being a demonstration, CMS initially decided to limit the scope to specific claim types and jurisdictions. Based on the effectiveness of the demonstration, CMS has authorized the expansion of the demonstration to include all DME claim types, with exception to claims or suppliers already subject to another CMS initiative (e.g. prior authorization for power mobility devices (PMDs) or the settlement conference facilitation (SCF) process).
Q. Are Power Mobility Device (PMD) appeals eligible for the demonstration?
A. PMD appeals are eligible for the demonstration if they are not/were not required by, or eligible for, a prior authorization process based on the date of service. Additional details regarding prior authorization activities are noted below.
In 2012, CMS implemented a Prior Authorization Demonstration for scooters and power wheelchairs for people with Fee-For-Service (FFS) Medicare who resided in the following states: MD, NJ, PA, IN, KY, OH, GA, TN, LA, MO, WA, AZ, CA, IL, MI, NY, NC, FL and TX. An appeal related to a claim that was submitted and processed prior to the implementation of the prior authorization process in the above states is eligible for the Telephone Discussion Demonstration. Appeals related to a claim(s) that was/were processed under the prior authorization demonstration are excluded from the Telephone Discussion Demonstration.
In 2017, CMS also implemented a permanent prior authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items frequently subject to unnecessary use, and selected two group 3 power mobility devices, which were not included in the prior authorization demonstration that began in 2012. An appeal related to a claim that was submitted and processed prior to the implementation of the permanent prior authorization process, related to group 3 power mobility devices, is eligible for the Telephone Discussion Demonstration. Appeals related to a claim(s) that was/were processed under the permanent prior authorization process are excluded from the Telephone Discussion Demonstration.
As of September 1, 2018, the PMD Demonstration that began in 2012 ended. However, CMS is continuing the prior authorization process for most PMDs nationwide. All new rental series claims for these PMDs with dates of service on or after September 1, 2018, require prior authorization as a condition of payment. As of September 1, 2018, CMS no longer requires prior authorization for the following: K0800, K0801, K0802, K0812, K0891 and K0898. Appeals for these PMDs, for new rental series after September 1, 2018, no longer require prior authorization and are eligible for review under the Telephone Discussion Demonstration. As noted above, an appeal related to a claim that was subject to prior authorization is excluded from the Telephone Discussion Demonstration.
More information on the Prior Authorization Demonstration for PMDs can be found here. More information on items that currently require prior authorization can be found here.
Q. What if I did not receive/misplaced the Telephone Discussion Demonstration Contact Information Form?
A. C2C can mail, fax, or email the information form to you. It can also be downloaded from the following link: Telephone Discussion Demonstration Contact Form (PDF).
Q. When will the decision be issued?
A. To account for scheduling and the provision of additional documentation on the part of the supplier, under the telephone discussion demonstration, the determination has a modified timeframe for the issuance of the decision. Instead of the standard 60 day reconsideration process, CMS has extended the time frame to 120 days from receipt of the reconsideration request.
Q. Why has the Telephone Discussion Demonstration been given 120 days?
A. CMS has allowed 120 days to provide ample time for scheduling, the discussion to take place, the additional documentation to be submitted, and review/consideration of the testimony and additional documentation that was received through the discussion process to complete the reconsideration.
Q. How are these telephone discussions scheduled?
A. The telephone discussions are scheduled once the appeal has been selected, as a part of the demonstration. You will be notified via the notification of participation letter.
Q. What if I can’t make the date?
A. To reschedule your Telephone Discussion, please submit a reschedule request in writing via fax or mail. Rescheduled discussions will be granted at the discretion of C2C Innovative Solutions, Inc.
Q. How do I re-schedule in case of an emergency?
A. Please call and leave a message at (904) 224-7349. C2C Innovative Solutions, Inc. will contact you regarding your request to reschedule. When leaving a message, please include your name, appeal number, and the best number to contact you.
Q. Are my appeal rights impacted by this telephone discussion?
A. No, subsequent appeal rights are not impacted by the Telephone Discussion Demonstration.
Q. Can I elect to participate in this discussion on my own behalf?
A. Yes, participation in this demonstration is voluntary. If you receive a notice that your appeal has been selected for participation in this demonstration and you do not wish to participate or do not agree with the 120 day processing timeframe, please call and leave a message at (904) 224-7349. C2C Innovative Solutions, Inc. will remove your information from the discussion. When leaving a message, please include your name, appeal number, and the best number to contact you should we have any questions.
Q. What if I have to cancel my telephone discussion?
A. What number should I contact and what info should I include? Please call and leave a message at (904) 224-7349. C2C Innovative Solutions, Inc. will contact you regarding your request to reschedule. When leaving a message, please include your name, appeal number, and the best number to contact you.
Q. I participated in a phone discussion and provided my additional documentation. When can I expect to receive my decision?
A. To account for scheduling and the provision of additional documentation on the part of the supplier, the phone discussion has a modified timeframe for the issuance of the decision. Instead of the standard 60 day reconsideration process, CMS has extended the time frame to 120 days.
Q. Why do I have to wait for my scheduled date?
A. Calls are scheduled to allow time for the reconsideration professional to research, receive and review all applicable and available documentation.
Q. What happens if I cannot find the documentation requested at today’s discussion?
A. A reconsideration professional will continue to make a determination on your appeal based upon the previously submitted documentation.
Q. How will I be notified of the date/time of my phone discussion?
A. The discussions are scheduled once the appeal has been selected as a part of the demonstration. You will be notified via mail in the form of the notification of participation letter.
Q. Where can I fax additional materials for consideration as part of the phone discussion?
A. Additional materials should be addressed to the following: Phone Discussions Fax Line of C2C Innovative Solutions, Inc. at (904) 224-2711.
Q. Can I escalate an appeal to the OMHA if I have elected to participate in this demonstration?
A. By agreeing to participate in the telephone discussion, you forfeit the opportunity to escalate your appeal to the OMHA. The term “escalate” in this scenario refers to accelerate or advance beyond the reconsideration level prior to the completion of its review. The appellant does, however, maintain the right to appeal to the OMHA, but not in the form of an escalation since the telephone discussions are not processed within 60 calendar days. In short, you may appeal to the OMHA after you have participated in the telephone discussion and a decision has been rendered, however it may not be escalated prior to the QIC’s conduction of the discussion.