Frequently Asked Questions

How can I find out more about the Demonstration?

CMS has additional information about the demonstration on its website. Read more about reconsiderations and the Demonstration here.

When does MAXIMUS Federal begin processing appeals as part of the Demonstration?

MAXIMUS Federal will begin processing all new requests for reconsideration for DME claims received on or after September 1, 2019. Appeals submitted prior to that date will continue to be processed by the previous QIC.

MAXIMUS Federal will also begin identifying new appeals as of this date for participation in the Demonstration. This includes selecting appeals that may benefit from the telephone discussion process and identifying appeals pending at the ALJ that may be reopened and found favorable.

Which appeals are eligible for the Demonstration?

As of November 1, 2018, appeals for claims in all DME MAC jurisdictions are eligible for this Demonstration. However, claims for glucose/diabetic testing supplies that originate in MAC jurisdictions A and B only are not currently eligible. Additionally, claims subject to another CMS initiative – such as appeals dealing with prior authorization for power mobility devices (PMDs), the settlement conference facilitation (SCF) process or the Serial Claims Initiative – are not considered for this Demonstration.

How will I know if my appeal was chosen for the formal telephone discussion?

MAXIMUS Federal will send the appellant a letter indicating that the appeal has been chosen and including a recommended time and date for the telephone discussion. The letter will have detailed instructions for how to respond if you choose to participate or decline and/or if a new date or time is needed.

What is the process for a telephone discussion?

MAXIMUS Federal will send the appellant a letter if the appeal is chosen for the Demonstration. This letter will include a preferred time and date for the discussion. The appellant will have 14 days to respond and indicate a choice to participate or not. Prior to the set date and time, a scheduling representative will contact the appellant via phone as a reminder.

At the time and date of the call, the QIC reconsideration expert will contact the appellant directly. The discussion will be recorded and included as part of the administrative case file.

Can I request a different date and/or time for the telephone discussion?

Yes. The letter informing the appellant that the appeal was chosen for the Demonstration will contain contact information the appellant may use to request a change in date and/or time. Appellants may also contact MAXIMUS Federal directly at MaximusQICDemo@maximus.com or 585-348-3202. Every effort will be made to select a date and time suitable for both parties.

How does my appeal process change as a result of participating in the telephone discussion process?

By agreeing to participate, the appellant agrees to allow 120 days to process the reconsideration appeal rather than the standard 60 days. This allows time to conduct the telephone discussion and for submission of any additional useful or required information. All other subsequent appeal rights remain unchanged.

What if I do not have or cannot locate the information requested during the telephone discussion?

Please respond within 14 calendar days indicating if that information is not available. MAXIMUS Federal will continue with the decision process based on the previously submitted information.

Can I escalate an appeal to the OMHA if I have elected to participate in the telephone discussion process?

“Escalation” refers to an accelerated or advanced appeal to OMHA prior to the completion of the QIC’s reconsideration. By agreeing to participate in the telephone discussion Demonstration, appellants are no longer able to escalate that particular appeal to the OMHA. However, appellants retain the right to appeal any unfavorable reconsideration decision to the OMHA for an ALJ hearing.

How will I know if my appeal was chosen for the reopening process?

MAXIMUS Federal will identify appeals for reopening where additional information may be provided to satisfy Medicare regulatory criteria, resulting in a favorable decision. In this situation, an additional documentation request (ADR) will be sent to the appellant. This letter will indicate the specific information required and the timeframe of 30 calendar days to return that information in order to support potential resolution of the appeal through this reopenings process.

There may be other situations in which an appeal may be reopened and found favorable without additional documentation. The appellant will be notified via mail that the appeal is being reopened.

A new decision letter will be sent to all parties if an appeal is reopened.

Can I request my appeal(s) be reopened under the Demonstration?

Yes. Please contact MAXIMUS Federal with detailed information, including the appeal number(s) and why the appeal(s) would benefit from the reopening process. MAXIMUS Federal will examine the appeal and any additional documentation received to determine if the appeal can now be resolved favorably through a reopening under this Demonstration. MAXIMUS Federal will contact the appellant if any additional information is required.

How can I send required information to you for reconsideration/reopening?

Information about how to securely send required information will be included in the reopening notice or additional documentation request (ADR). The information may be sent directly through the QIC Appeals Portal (https://qicappeals.cms.gov) or via mail (please include the appeal number and detailed response to our request) at the address below:
MAXIMUS Federal
Formal Telephone Discussion and Reopening Process Demonstration
3750 Monroe Avenue, Suite 777
Pittsford, NY 14534-1302

What should I do if my mailing address or phone number has changed since I mailed in my Reconsideration Request?

Please call us at 585-348-3200 to provide your updated address and phone number.

What if I have to cancel my telephone discussion?

Please call and leave a message at 585-348-3202. MAXIMUS will contact you regarding your request to reschedule. When leaving a message, please include your name, appeal number, and the best number to contact you.

Medicare Durable Medical Equipment (DME) Appeals