Last Modified: 10/2/2020
Business: Part A
C2C Innovative Solutions, the Part A East Qualified Independent Contractor (QIC), has the authority to conduct reopenings on previously adjudicated unfavorable claims with appeal dates on or after July 1, 2015, that are currently pending third level appeal or Administrative Law Judge assignment at the Office of Medicare Hearings and Appeals (OMHA). C2C can also conduct reopenings on unfavorable reconsiderations that have been decided by the QIC, but not yet appealed to OMHA. Further, the QIC assists providers in submitting withdrawal requests to OMHA when, through the course of the Demonstration activities, the provider/supplier decides to discontinue pursuing appeal(s) currently pending at OMHA.
C2C is conducting a voluntary telephone discussion demonstration that gives providers the opportunity to speak with a reconsideration professional in order to provide verbal testimony and any additional documentation that would assist in a possible favorable determination. After the scheduled telephone discussion takes place, C2C will review the documentation in the case, along with Medicare rules and policies, to make a decision on the appeal. If the service was denied as not being medically necessary, C2C will ask a clinical panel to review the claim/case.
The telephone discussions offered under this demonstration have a modified timeframe for the issuance of the QIC’s decision. Instead of the standard 60 days, the Centers for Medicare & Medicaid Services (CMS) extended the time frame to issue C2C’s decision under this demonstration to 120 days. If the provider is dissatisfied with C2C’s decision, they will continue to have appeal rights to OMHA.
The benefits of participating in the telephone discussions include:
• Provides an opportunity for the Part A East provider community to verbally discuss their case with a decision maker before a QIC decision is made;
• Allows the providers to understand what documents the decision maker has in the QIC case file and what documents are missing that are critical to the outcome of a case;
• Provides the opportunity for additional documentation that supports a favorable appeal decision to be faxed, or transmitted through other secured means, to the QIC decision maker prior to the reconsideration decision being made; and
• Educates providers on CMS policies and requirements.
By agreeing to participate in the telephone discussion, providers forfeit the opportunity to escalate their appeal to OMHA. The term “escalate” in this scenario refers to accelerate or advance beyond the reconsideration level prior to the completion of its review. However, the provider does maintain the right to appeal to OMHA, but not in the form of an escalation if the telephone discussion is not processed within 60 calendar days. In short, the supplier may appeal to OMHA after they 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 telephone discussion.
Reopening process demonstration
As a component of the Medicare appeals demonstration, C2C will conduct an analysis on provider appeal decisions that have been rendered by the QIC and closed. As a result of the analysis, C2C will present its findings and claims for potential reopenings to providers. When reopenings are possible, C2C will work in conjunction with OMHA to facilitate the remanding of the case to the QIC.
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