Purpose of the Formal Telephone Discussion Demonstration
The purpose of the Formal Telephone Discussion Demonstration is to give suppliers the opportunity to participate in a formal 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 Formal Telephone Discussion Demonstration is voluntary. The Formal Telephone Discussion Demonstration is currently limited to appeals submitted by suppliers within Durable Medical Equipment (DME) MAC Jurisdictions C (CGS) and D (Noridian). Effective on, or after, October 31, 2016, the service types under this demonstration include all appeal types, with exception to claims or suppliers that are already subject to another CMS initiative (e.g. prior authorization for power mobility devices (PMDs) or the settlement conference facilitation (SCF) process). The Formal Telephone Discussion Demonstration will allow the supplier community the opportunity to present the facts of the case and/or submit additional written documentation at the QIC level.
Upon receipt of a valid reconsideration request, the QIC shall identify cases/claims that would benefit from the discussion process under this demonstration. Between two and six weeks of receipt of an appeal, suppliers may receive an invitation to participate. C2C will issue a form letter notifying the supplier that the claim has been selected to participate in the Formal Telephone Discussion Demonstration. The supplier will be afforded 14 calendar days from the date of the notification letter to respond by returning the forms enclosed with the letter, and indicate whether they wish to participate in this voluntary Formal Telephone Discussion Demonstration.
If the supplier concurs with the request to participate in the Formal Telephone Discussion Demonstration, C2C will conduct the formal telephone discussions with suppliers and shall be specific in clarifying Medicare policies and requirements, educating the supplier, and identifying any materials, evidence, and/or documentation that would yield a favorable outcome as part of the reconsideration process. After the formal telephone discussion is held, 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 formal telephone discussion. After reviewing all documentation available, the reconsideration professional will issue a decision on the case.
Note: The formal telephone discussion has a modified timeframe for the issuance of the decision. Under this demonstration, the QIC shall have 120 days to process the reconsideration, rather than the existing 60 day standard.
C2C Innovative Solutions, Inc.
QIC DME- Formal Telephone Discussion Demonstration
P.O. Box 44044
Jacksonville, FL 32202-5103
Telephone: (904) 224-7349
Fax: (904) 224-2711