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In Case You Haven’t Heard – News For Jurisdiction C and D Suppliers

At the Medtrade Spring Jurisdiction D council meeting, C2C Innovation Solutions shared updates with the supplier community.  Currently there is a demonstration project that consists of two phases in Jurisdiction C and D only for diabetic testing strips and oxygen equipment.

The first phase has allowed suppliers the opportunity to participate in a formal recorded telephone discussion with QIC, C2C and offer verbal testimony.  The selected DME suppliers will be able to discuss the facts of the case and provide any additional documentation that would assist in reaching a favorable determination. The second phase of the demonstration is with reopenings.  C2C will be able to look at those claims found unfavorable or partially unfavorable that are in the ALJ.  They can only go back to January 1, 2013—which is the C2C decision date on the letter, not the date of service. The contractor will only open up those claims that they feel can be overturned to a favorable decision.   Don’t worry as you will not lose your place in line at the ALJ if they don’t see where the claim can be found favorable.  Remember these current phases have only been for oxygen equipment and diabetic testing strips in Jurisdiction C and D.

For both phases of this demonstration, selected suppliers receive a letter that invites them to a scheduled phone discussion. The supplier has 14 days to respond to the letter.  If the supplier opts not to have a phone discussion, a response is still needed –follow the instructions in the letter.  If no response is received, the contractor will reach out to the supplier.  The discussion can be about technical issues or medical necessity meaning if something is missing or can be obtained easily by the supplier, this can be accomplished during the discussion with the reviewer.

Instead of the 60 day timeframe, if the appeal was selected for this demonstration, there is a 120 day timeframe to allow for scheduling, the discussion to take place, additional documentation to be submitted, and to review the testimony and additional documentation that was received through the discussion process.

Continue to submit your appeals as normal.  Watch for those letters in case you are selected to participate in the phone discussion where you can give a testimonial as to why the claim is payable.  The reviewer nurse will then take that information and make a determination.   If the decision does come back as unfavorable, you still have appeal rights which means going to the next level at ALJ.

New News from Medtrade Spring

C2C shared with the group at Jurisdiction D DAC meeting that since the demonstration started, there has been 12,000 claims reviewed and 80% of those claims were overturned in favor of the supplier.  The suppliers that follow the traditional process with reconsiderations, the overturn rate is at 30%.

Is the demonstration being expanded to other areas?   YES all other DME except power wheelchairs.

What is the effective date for the new areas?   SOON—stay tuned for effective date.

If you currently have claims at the ALJ for any product category except power wheelchairs, you can request the C2C to review for a possible reopening—and you can do this now. Go to where you will find the form to complete.  If you have a large volume sitting at C2C or ALJ, let me know so you can be connected with someone at C2C and they will let you submit a spreadsheet instead of completing forms for each individual case.  If they cannot reopen the claim, you will not lose you place in line at the ALJ.

Now for suppliers in Jurisdiction A and B, you are considered a control group for this demonstration.  However, requests can be submitted for CMS to consider opening up this project to your Jurisdiction.  What you need to do is email C2C with the request to expand it to Jurisdiction A or B.  Send the requests to   Suppliers in Jurisdiction A and B—send in your requests!!

An important note, C2C uses the contact information submitted with the appeal letter.  Make sure all the staff is aware of this information.  The reason is there has been concern with some suppliers lack of response the letter and to telephone calls from C2C.   This is a good opportunity for suppliers, especially those that have many claims pending at reconsiderations and at the ALJ.

Check out the C2C Innovation Solutions website for information.   Let me know if you have any further questions.


Ronda Buhrmester