CMS announced last week the second level of appeals demonstration project is expanding into both Jurisdictions A and B. The demonstration project is set to begin Nov. 1, 2018, for all product categories except diabetic testing supplies and any other projects involved in CMS initiative such as the Prior Authorization for PMDs.
See below for information from The VGM Group and Ronda Buhrmester, VGM’s director of Reimbursement for VGM who along with industry associations, has been pushing CMS to get this expanded into jurisdictions A and B for several years.
“We are thrilled to see the expansion of this demonstration project into the other jurisdictions,” said Buhrmester. “In August 2017, VGM and several members testified at a hearing with the Small Business Administration (SBA) proposing the program’s expansion to streamline the appeals process. At the federal level, SBA expressed a great deal of interest in establishing their support of the project, being involved in the process after the hearing.”
The demonstration project started back in January 2016 and consisted of two phases that only applied to jurisdictions C and D. The demonstration has been approved for five years. Until now, jurisdictions A and B have been part of the control group.
See the full announcement from CMS by clicking here.
The first phase of the project has given suppliers the opportunity to participate in a formal telephone discussion with C2C and offer verbal testimony. The DME suppliers 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 Jan. 1, 2013—which is the C2C decision date on the letter, not the date of service. The contractor will open up only 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.
For both phases of this demonstration, selected suppliers receive a letter that invites them to a scheduled phone discussion. 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.
C2C has shared since the demonstration started with the formal telephone discussions the success of getting claims in a favorable state and decreasing the ALJ backlog.
If you currently have claims at the ALJ, you can request the C2C to review for a possible reopening—and you can do this now. Go to www.C2Cinc.com where you will find the form to complete. If you have a large volume sitting at C2C or ALJ, let us 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.
Also, if you are submitting a claim for the first time reconsideration and you would like a formal telephone discussion, write this on the reconsideration form. C2C will take this into consideration.
An important note, C2C uses the contact information submitted with the appeal letter. Make sure all of your staff is aware of this information. This is a good opportunity for suppliers, especially those who have many claims pending at reconsiderations and at the ALJ. If you miss the deadline for the telephone discussion, you will be going through the standard reconsideration process. This is imperative to know because under the demonstration project, the C2C contractor is allowed to be more flexible with the coverage criteria and regulations. Outside of the demonstration project, going through the standard reconsideration process, the normal medical policies, rules, and regulations apply.
Check out the C2C Innovation Solutions website for information.