Appeals Demonstration Expanded to Home Health & Hospice

WASHINGTON, D.C. (December 5, 2019)—On Jan.1, 2016, the Centers for Medicare & Medicaid Services (CMS) launched the Qualified Independent Contractor (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 Medicare Administrative Contractor (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 some exceptions.

Effective May 1, 2019, CMS further expanded the demonstration activities to the Part A East (PAE) QIC jurisdiction. Under the expanded demonstration, the PAE QIC is offering telephone discussions and/or re-openings to Part A, which includes home health and hospice providers in the PAE states. For home health and hospice providers, below are the following MACs and eligible states for the demonstration.

FFS Medicare Home Health and Hospice Appeals Eligible for QIC Demonstration

Palmetto—JM    Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas

CGS—J15         Colorado, Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

NGS—JK          Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

NGS—J6          New Jersey, New York, Puerto Rico, U.S. Virgin Islands

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 re-openings under the demonstration.

Upon receipt of a valid reconsideration request, the QIC will identify cases/claims that would benefit from the telephone discussion process under this demonstration. Between two and six weeks of receipt of an appeal, identified providers/suppliers may receive an invitation to participate in the demonstration. C2C Innovative Solutions Inc., the QIC for Part A east, will issue a form letter notifying the provider 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 to clarify Medicare policies and requirements, provide education, and identify 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 Demonstration incudes a reopening process for claims that are currently pending Administrative Law Judge (ALJ) assignment at the Office of Medicare Hearings and Appeals (OMHA). Reopenings are limited to ALJ request for hearing dates of: April 2017 to current.

The provider will be notified in writing if an appeal is identified as a potential reopening, along with the missing or insufficient documentation required to allow payment. Providers have 30 days from the date of the letter to return requested documentation. If the requested documentation is not received, C2C will not proceed with the reopening.

Upon receipt of the requested documentation, C2C will confirm that the documents support a favorable decision. If the documentation supports a favorable decision, C2C will reopen and render a favorable decision. If a favorable decision cannot be rendered, the provider will be notified in writing, and the appeal will remain at OMHA and will not lose placement at the ALJ

Additionally, providers may submit a request for a potential reopening that currently have appeals at the ALJ awaiting a hearing. The reopening request form is located on the C2C website.

The demonstration is scheduled to run until the end of 2020.

Home health and hospice providers should keep a look out for letters from C2C Innovative Solutions. Inc. inviting participation in the demonstration, and consider requesting reopenings for any appeals at the ALJ level.

Click here for more information on the PAE demonstration.