QIC Telephone Discussion and Reopening Process Demonstration

Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration

Update: CMS Expands the Demonstration to Part A

Demonstration Background:

On January 01, 2016, CMS launched a the QIC Telephone Discussion and Reopening Process Demonstration to test whether further engagement between Durable Medical Equipment (DME) suppliers and the DME QIC will improve the understanding of the cause of appeal denials, and over time, result in more proper claim submission at the DME MAC level from suppliers participating in the Demonstration. The Demonstration initially focused on oxygen and glucose/diabetic testing strip supplies. However, on October 1, 2016, CMS expanded the Demonstration to include all DME claim types within DME MAC Jurisdictions C and D, with exception to claims or suppliers that were already subject to another Centers for Medicare & Medicaid Services (CMS) initiative (e.g., Prior Authorization for Power Mobility Devices (PMDs), Settlement Conference Facilitation (SCF)).

On May 1, 2019, the Demonstration was expanded to the Part A East QIC Jurisdiction to include all Part A claim types within MAC Jurisdictions H, J, K, L, M, and N, and home health and hospice (HHH) related appeals within MAC Jurisdictions J6 and J15.  Reconsiderations for service termination, hospital discharge reviews and claims or providers that are already involved in another CMS initiative (e.g. Settlement Conference Facilitation) are not eligible for telephone discussions and/or reopenings under the Demonstration. Under the Demonstration, the QIC reviews reconsideration requests to identify appeals that may benefit from participation in the telephone discussion process. Eligible providers and suppliers are offered the opportunity to engage in a recorded telephone discussion of appealed claims with the QIC prior to the issuance of the reconsideration decision. Participation in the telephone discussion is voluntary. The telephone discussion process allows suppliers to discuss the facts of the case with the QIC and to submit any missing/critical documentation identified by the QIC, as needed, to support a favorable resolution, prior to the QIC rendering a decision. This process also works to educate the supplier community on Medicare coverage policies, the root causes of denials, and any trends associated with documents that are critical to the outcome of an appeal.

As part of the Demonstration, the QIC is also conducting analysis on previously completed unfavorable reconsideration decisions dated on or after January 1, 2013, to identify potential appeals that can now be resolved favorably through the reopening process. Under this Demonstration, the QIC has the authority to conduct reopenings on previously adjudicated unfavorable claims that are currently pending ALJ assignment at OMHA, and/or unfavorable reconsiderations that have been decided by the QIC, but not yet appealed to OMHA. Further, the QIC assists suppliers in submitting withdrawal requests to OMHA when, through the course of the Demonstration activities, the supplier determines that they no longer wish to continue pursuing appeal(s) currently pending at OMHA.

For more information on this Demonstration, see the links below in the “Downloads” section.

Page Last Modified:
01/15/2020 05:00 PM