FAQs Related to the PAE Telephone Discussion and Reopening Process Demonstration
Q. Are my appeal rights affected by my participation in a telephone discussion? Will I lose my right to appeal to OMHA if I am dissatisfied with the reconsideration decision?
A. No, subsequent appeal rights are not affected by the Telephone Discussion Demonstration. You still have the right to appeal to OMHA if you participate in the Appeals Demonstration.
Q. Can I escalate an appeal to the OMHA after 60 days if I have elected to participate in a telephone discussion?
A. By choosing to participate in the telephone discussion, you agree to a 120 day reconsideration decision timeframe, and will not have the opportunity to escalate your appeal to the OMHA if the QIC has not completed its decision within 60 days. 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 once the decision is rendered, 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.
Q. How long will the Demonstration be available?
A. The Demonstration is approved to continue through December 31, 2021.
Q. Why has the QIC been given 120 days to complete adjudication of my reconsideration when I participate in a telephone discussion?
A. CMS has allowed 120 days to provide ample time for scheduling, the discussion to take place, the additional documentation to be submitted, and for consideration of the testimony and additional documentation that was received through the discussion process to complete the reconsideration.
Q. How will I be notified of the date and time of my telephone 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 and Scheduling letter.
Q. What if I can’t make the date and/or time of the scheduled telephone discussion?
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. 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. How do I reschedule in case of an emergency?
A. Please call and leave a message at 904-224-7371. 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 telephone discussion and provided my additional documentation. When can I expect to receive my reconsideration decision?
A. To account for scheduling and the submission of additional documentation by the provider, 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 timeframe to 120 days.
General FAQs Related to the Demonstration
Q. Who should participate in a telephone discussion?
A. We always ask that the individual(s) who participate in the phone discussion are knowledgeable about the appeal, or have the ability to obtain additional documentation if it is requested. Below are some different job roles that may want to participate:
- The nurse that treated the patient - This is not necessary but up to the facility. We just need someone that can speak on behalf of your company that is familiar with the issues related to the appeal and Medicare guidelines.
- The administrator -This is up to the facility but not necessary.
- The third party reviewer that helped prepare the appeal - If they are the person that is most familiar and able to speak regarding the appeal, then they can attend and speak on your behalf. If they are the only one participating during the Telephone Discussion with no representation from your company, we will need an Appointment of Representative to conduct the phone call with them.
- Attorney – This is not necessary since this is not a legal proceeding. Our review team only looks at the claim from a Medicare policy standpoint.
- Management company - This is up to the facility. There have been some providers who participate in phone discussions where there are several people on the phone to listen, but they do not actively participate. We also have calls where several people from the provider participate in the call to discuss different aspects of the appeal.
Q. Can you provide a format for how the telephone discussions are conducted?
A. The call will be held with a reconsideration professional (reviewer), who has specific knowledge of the appeal.
- How much time does a call take per patient? Time per patient is dependent on the issues related to the appeal and the number of claims. The first call we ever hold with a provider usually takes longer because there are questions/information related to the process itself. However, on average, we schedule 30 minutes per call and most do not last the entire 30 minutes. If there are a large number of beneficiaries under one appeal or large number of claims, we can/do allow additional time.
- During the call do we review each Certification period or just overarching themes per patient? The C2C reviewer will discuss all denial reasons related to your appeal. There may be a repetitive documentation issue that is in every certification period which can be discussed all together; but, there are times when we discuss the certification periods separately.
- Will we hold phone discussions on multiple patients on the same day? We can do whatever works best for your facility. Some providers are able to hold back to back calls on multiple beneficiaries and we have other providers that hold several individual calls per week. If you have any scheduling questions, you can contact the scheduling department at 904-224-7371.
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. If selected, you will be mailed a Notification and Scheduling letter, containing details about your scheduled call and how to participate.
Q. May I decline to participate in a telephone discussion?
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 904-224-7371. C2C Innovative Solutions, Inc. will cancel your scheduled discussion, your appeal will continue through the standard reconsideration process and will be completed within 74 days from the day the appeal was received by C2C. 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 did not receive or 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. What if I have to cancel my telephone discussion?
A. Please call and leave a message at 904-224-7371. 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. Where can I fax additional materials for consideration as part of the phone discussion?
A. Additional materials should be addressed to the following: QIC PAE – Phone Discussions Fax Line of C2C Innovative Solutions, Inc. at 904-224-2732.
Q. What happens if I cannot find and do not submit the documentation requested prior to or during the telephone discussion?
A. A reconsideration professional will continue to make a determination on your appeal based upon the previously submitted documentation.
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 ADemoFeedback@c2cinc.com.
Q. What should I do if I believe I have an appeal pending at OMHA that could now be resolved favorably through submission of additional documentation to the QIC and potential reopening by the QIC under this Demonstration?
A. Please email us your NPI, QIC appeal number, date appealed to the ALJ, and a contact telephone number in case we have any questions, to ADemoFeedback@c2cinc.com.