Telephone Discussion Process Overview

The telephone discussion process under the Demonstration allows suppliers and QIC reconsideration experts to communicate during the reconsideration period and present additional details or information that will assist with the appeal review.

Upon receipt of a valid reconsideration request for a DME claim, MAXIMUS Federal will identify appeals that would benefit from the telephone discussion process. All appeals are eligible for this process except for:

  • Claims that are subject to another CMS initiative (e.g. prior authorization for power mobility devices (PMDs), the settlement conference facilitation (SCF) process, etc.) or
  • Claims for glucose/diabetic testing supplies in DME MAC Jurisdictions A and B.

The telephone discussion process will have the following objectives:

  • Educate the supplier regarding Medicare regulatory guidance and coverage rules that pertain to the appeal, including national and local coverage determinations, regulations and sub-regulatory guidance.
  • If applicable, identify any missing or incomplete documentation associated with the appeal that, if provided, may result in a favorable decision. This information may include verbal testimony regarding details about the appeal or documentation that should be included as part of the case file. If new information is identified during the call and must be submitted, the supplier will have 14 calendar days following the telephone discussion to provide it.

If an appeal is selected for participation in this process, MAXIMUS Federal will send the supplier an invitation letter through the mail, identifying a day and time for the telephone discussion to be conducted. The telephone discussion process is voluntary, and if the supplier chooses not to participate, the standard reconsideration appeal process will continue.

If the supplier wishes to participate, a response via secure fax (preferred), mail or phone is required within 14 days. The scheduling letter will contain appropriate contact information, which is also included on this website. An alternative date and/or time that suits both parties may be chosen if required.

MAXIMUS Federal will contact the supplier prior to the scheduled date as a reminder of the appointment. At the scheduled time, the QIC reconsideration expert will contact the supplier’s representative to conduct the telephone discussion. This discussion will be recorded and included as part of the administrative case file forwarded to the OMHA.

As part of the Demonstration process, for those appeals in which the supplier chooses to participate, the QIC will extend its timeframes for making a reconsideration decision to 120 calendar days (rather than the usual 60 days). This allows time for the telephone discussion and delivery of any required information.

Medicare Durable Medical Equipment (DME) Appeals