Part A East

Appeals Demonstration

C2C Innovative Solutions, Inc. (C2C) is a Qualified Independent Contractor (QIC) for Medicare Part A for 26 eastern states, Washington D.C. and two U.S. territories. This jurisdiction also includes reconsiderations involving MSP recoveries. The jurisdiction is referred to as QIC Part A East.

Part A East Telephone Discussions

The Telephone Discussions give providers the opportunity to speak with reconsideration professionals in order to provide verbal testimony and additional documentation that could assist in a possible favorable determination. The Telephone Discussion Demonstration will yield the following benefits:

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  • Provides an opportunity for the provider community to verbally discuss the case with a decision maker before a QIC decision is made;

  • Informs the provider what documents are present in the QIC case file and what documents are needed and are critical to the outcome of a case;

  • Provides the opportunity to fax or transmit through other secured media additional documentation that supports a favorable appeals decision to the QIC decision maker prior to the reconsideration decision being made; and

  • Assists and educates providers on CMS policies and requirements.

 

The service types under this Demonstration will include all claim types with the only exception to this opportunity being expedited appeals resulting from service terminations denials conducted by Quality Improvement Organizations (QIOs) and claims or providers that are already subject to another CMS initiative (e.g. the Settlement Conference Facilitation (SCF) process, etc.)

 

If an appeal is selected for the Telephone Discussion Demonstration, the QIC will notify the provider via mail with a scheduled time and date for the Telephone Discussion to be conducted. Participation in this demonstration is voluntary. In order to participate the provider will need to reply by returning the form enclosed with the election acknowledgement letter contact information form via mail or fax within the timeframe indicated in the letter. Note: The telephone discussion has a modified timeframe for the issuance of the decision. Under this Demonstration, the QIC shall have 120 days to process the reconsideration, rather than the existing 60-day standard.

 

If you have questions regarding the Telephone Discussion Demonstration, you may call us at (904) 224-7371.

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PAE Reopening Process

As a component of the Appeals Demonstration, C2C will conduct analysis on completed unfavorable claims dated on or after Jan. 1, 2013, and currently pending a decision at the Administrative Law Judge (ALJ). As a result of the analysis, C2C will present its findings and a list of claims of potential reopenings to the respective providers.

 

The universe of appeals which may be reopened by C2C under this demonstration may include cases that have been closed by the Qualified Independent Contractor (QIC) in the past 60 days and have not yet been appealed to the Administrative Law Judge (ALJ), as well as cases that have been appealed to the ALJ and are currently pending. As a reminder, if you intend to submit an appeal to the ALJ, it must be submitted within 60 days from the QIC decision date.

 

After the QIC receives the requested documentation, the QIC will review the materials received to confirm all requested documentation was received and determine if a reopening is warranted. The reopening shall only occur upon receipt of and C2Cā€™s verification of the missing or otherwise relevant documentation that would yield the favorable decision. Participants will receive a letter notifying them if the case can or cannot be reopened after C2C has completed this review.

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  1. If the case or cases are currently pending at the ALJ, C2C will review the documentation received and if it is determined that the claim can be resolved favorably through a QIC reopening, C2C will work with the ALJ to remand the case back to the QIC for processing of the reopening.

  2. If a provider no longer wishes to continue the appeal pending before the ALJ, C2C can assist with withdrawing the appeal. C2C will furnish the provider with a withdrawal request spreadsheet, along with form HHS-730 (Withdrawal of request for an Administrative Law Judge (ALJ) Hearing). If you have questions regarding the withdrawal process, you may call us at (904) 224-7371

 

Additional details regarding the reopening process will be provided by C2C during the telephone discussion for the claims that are selected for the participating providers.

Part A East Forms

Supporting Documentation Cover Letter

Reopening Process Cover Letter

Telephone Discussion Contact Form

Withdraw Hearing Request, Form HHS 730

Contact:
Schedules:

GSA Schedule 36

GSA Professional Services Schedule (PSS)

Accreditations:

ISO 9001: 2015 Registered

URAC Internal/External

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DUNS:

929125818

NAICS Codes: 

541611, 541612, 541614, 541618, 541990, 923120, 524291, 524298, 561110, 561421, 561439, 561499, 518210, 621111, 923140