Present: Providers/Members
Dale Clevland Reid Bellis Kim Frushon Velma Goertzen
Chuck Gunther Maureen Hanna Mike Hayden Wade Hendrickson
Dave Hosman Vickie Houghton John Kenney Herb Langsam
Laura Mc Ilvaine Sharon Nichelson Troy Paz Kim Rogers-Bowers
Carlos Reyes Gloria Peterson Rich Pozesky Val Taylor
HCFA (Seattle):
Jim Underhill
CIGNA Staff (Boise):
Melissa Atwood Dolly Baughman Carla Cerchione Lisa Fix
Doug Frazier Melissa Hansen Nicole Pichardo Dina Reynolds
Klayton Weybright Amanda Zumwalt
CIGNA (Nashville):
Dr. Robert Hoover Ellen Edenfield Dr. Doran Edwards Trisha Luna
Mary Rheinecker Shelly Tant
Carlos Reyes called the meeting to order at 11:40 a.m. (PST).
No question on the last meeting minutes.
Health Insurance Portability and Accountability Act (HIPAA)
Klayton Weybright provided an update on HIPAA. HCFA’s goal is to standardize the
electronic submission industry wide. Additional information will be sent out by e-mail.
It was agreed that the DAC EDI/EMC A-Team would schedule a conference call within
approximately 2 weeks with the CIGNA to discuss HIPAA . The focus of the call will be
to allow the Team to establish familiarity for future communication about HIPAA.
Arrangements to begin these discussions will be done by contacting the EDI Marketing
Department at 208.333.2157 (Nicole’s direct line).
A-Team leaders were given the opportunity to comment on CIGNA’s response to
questions submitted prior to the call. The following A-Teams had additional concerns:
Education/Communication, Medical Supplies, O&P, Rehab, and Respiratory.
Education /Communication (Maureen Hanna)
#2b. Maureen Hanna stated her concern over the answer. Dr. Hoover stated it was the
responsibility of the providers to keep updated. Maureen Hanna stated that most
providers don’t know what the PIM is, and that CIGNA should refer to it more often, in
the DMERC Dialogue and other provider correspondence.
#4. Maureen Hanna asked if the DAC would ever be able to get the minutes posted to
its web site. Dr. Hoover stated it should really be the DAC’s responsibility to have a web
site, as it can be very cost prohibitive, as far as space and programming and updates.
Carlos stated it is something the DAC would look into.
#8. Dr. Hoover once again stated his thanks for the offer of in-services. They usually
come from manufacturers and the nursing staff attends. Dr. Hoover stated it becomes a
scheduling problem, but the DAC is on the list.
Medical Supplies (Sharon Nichelson)
#2. Sharon Nichelson stated that the codes were off. Dr. Hoover stated he would look
into it. Dr. Hoover’s staff stated that Sharon Nichelson was correct and that all the codes
from K0428 down may be off and an update would be sent out.
Orthotics and Prosthetics (John Kenny)
#1. John Kenney stated his concern on codes, and the process for comment & review.
Dr. Hoover sated coding is separate than policy, and coding is made up of different
groups. John Kenney stated that the DAC should be part of the process. Dr. Hoover
suggested John Kenney contact Kay Riley at HCFA to get more information. Dr. Hoover
also recommended that the O&P A-Team send a letter to him and he would forward it to
the proper people at HCFA.
#2. John Kenney asked if CIGNA considers documentation provided by technicians,
therapist, etc. to be part of the physician file. Dr. Hoover stated that they look at
everything and collaboration between everything to make the proper decision.
#4. Jim Underhill still has no update on this yet.
#5. John Kenney will submit additional examples to Gloria at the DAC office who will
forward them to Dolly Baughman, CIGNA.
Rehab (Reid Bellis)
Reid Bellis announced that the DAC Rehab ‘A’ Team has developed a specialty
committee that is currently working to gather information requested by Dr. Hoover to aid
in the development of the prior authorization process. Reid thanked Dr. Hoover for the
opportunity to work on the prior authorization process.
#2. Reid Bellis stated they would put more information in writing so they can get an
answer in writing.
#3. Reid Bellis asked the percent volume cause the documentation to go up. Dr.
Hoover stated it is data driven, and they look at a lot of different data, fraud, quantity,
and billing pattern. Mary stated it is not a bad idea to send as much as you have with a
claim, especially if a chair is going to cost as much as a car.
Respiratory (Dale Cleveland)
#1. Dale Cleveland stated the DAC’s concern with HCFA Transmittal 1685, and
requested a direct contact at HCFA the DAC could address on this issue. Dr. Hoover
stated that this was not going away and is going to happen, but they have bumped the
date back. DAC stated that we would keep fighting the issue.
#4. Dr. Hoover stated to make sure to include whom the subscriber was with and will
not be retroactive, info is posted on the website.
Carla & Gloria will coordinate the dates and time of the next meeting to be held at
Medtrade West in Las Vegas, NV.
The meeting was adjourned.

Present
Members:
Greg Lord Barbara Harris
Val Taylor Janna Jurovich
Wade Hendrickson Kimberlie Rogers-Bowers
Chuck Gunther Que Christensen
Carlos Reyes Laura McIlvaine
Troy Paz Rich Pozesky
Kel Bergman John Kenney
Mark Caspers Ed Arnold
Asela Cuervo Diana Guth
Tami Joplin Fay Bares
Ed Erickson Vince DeStigter
Doug Thole Dave Warrilow
Tim Pontius Dale Cleveland
Steven J. Knoll Que Christensen
Violeta Arnobit Maureen Hanna
Reid Bellis
CIGNA Staff:
Robert Hoover, M.D. Carla Cerchione
Dolly Baughman Ellen Edenfield
Amanda Zumwalt
HCFA Staff:
Jim Underhill
The meeting began with introductions of CIGNA and HCFA staff and DAC members
present.
Carla Cerchione reviewed the function of the Nashville and Boise offices. Nashville
processes claims, while Boise houses Provider Relations staff.
Minutes from the last meeting were approved and accepted.
The Spring Seminar schedule has been established by CIGNA with cooperation from the
Education A-Team. Seminar sign-up is available on the CIGNA website. The DAC was
asked to have representatives at each of the sites to introduce the DAC and function.
CIGNA will not charge for the seminars as directed by HCFA. However, there will be a
small charge to cover the costs of refreshments provided. The DAC representatives that
will attend the seminars will be forwarded under separate cover to Dolly Baughman.
2
Dr. Hoover reiterated CIGNA’s willingness to allow the DAC to place articles in the
DMERC Dialogue, space permitting. The budgeting process for production of the
DMERC Dialogue is established annually based upon projected number of pages.
Budget constraints and space needed for DMERC articles will be the determining factors
as to whether space will be available for DAC articles.
Dr. Hoover provided the following updates:
• Providers should have received copies of the new Region D Supplier Manual. The
updated manual incorporates some of the information previously contained in
Dialogue articles. The policy section has been completely reorganized and as
updates occur, that the entire policy will be replaced, rather than issuing replacement
pages. Each of the policies also contains a revision history that can be found at the
end of the policy.
• The Spring DMERC Dialogue was available on the CIGNA website at the end of
March.
• Physician Assistants will be able to sign written orders for Medicare covered items
effective July 1, 2001. The requirements that must be met in order for the
prescription to be valid are included in the Spring DMERC Dialogue.
• The DMERC Medical Directors are currently reviewing the CPAP and Oxygen retesting
policies. A broad range of input will be requested prior to finalizing new
policies.
• BIPA and HIPAA are also issues being reviewed at this time. Some questions being
submitted cannot be answered by the DMERC because additional clarification is
required from HCFA.
• The mandatory assignment rule for drugs is now effective.
• The Advanced Determination of Medicare coverage is anticipated to be implemented
October 1, 2001. Prior authorization requests for POVs received after August 31,
2001, will not be accepted. Power wheelchairs will be the first item to be reviewed
through the system. Inclusion of other items will be considered once the DMERC can
evaluate the response for the initial period.
Other udpates provided by DMERC and HCFA Staff:
The upcoming Spring Seminars will include the information that is required for an appeal
request beginning May 1, 2001. If incomplete requests are received after that date, they
will be returned to the provider.
HIPAA requirements are expected to be a major issue for all areas of health care.
Providers should be preparing for the anticipated changes. Providers are encouraged to
check the CIGNA website for updates on this issue. This item will remain as a standing
item on the DAC meeting agenda.
3
Jim Underhill reiterated the importance of preparing for HIPAA. He suggested building
into business plans what will be required, analyzing internal systems to determine what
changes may be required and checking with external parties to ensure they are
compliant. HCFA will work with the states to help encourage state compliance. He will
check to see if he can provide a list of HCFA representatives that will work with the
respective Medicaid programs and report at the next DAC meeting.
Skilled Nursing Facility Consolidated for Part A covered stay is in effect. Part B
consolidated billing requirements have been repealed.
Question and Answer follow up:
The following clarifications were requested on the written response provided by CIGNA:
Respiratory:
Question 1: Is there any further comment on the meeting with NAMDRC?
The initial meeting had more of a "fact finding" goal. Generally, if a policy is in
development, the DMERC Medical Directors will initially contact a focused organization
for input. NAMDRC is a clinical organization. Once a draft is developed, it will be
provided to the supplier community for comment.
Question 3: If a CMN indicates a "lifetime" need, is an additional prescription still
required for supplies?
This item is still under review and no additional information was provided.
Question 6: Is 4 LPM the specific rate for additional tests?
Yes.
Medical Supplies:
Question 1: Is this a change in existing claim processing? If so, how will a request for
additional information be received by a supplier?
Instructions have been provided to ensure consistency in claims processing, not
requiring comments on all claims. If additional information is required, it will most likely
be requested in the format of a development letter.
Question 2: Was the issue clarified?
HCFA is currently evaluating and expected to be close to a resolution. The Program
Integrity Manual is an internal guide that combines other manuals, but does not
supercede regulation or the Social Security Act. Jim Underhill will inform the DAC of the
outcome of HCFA’s review.
4
Question 5a: Additional information is required to effectively answer the question.
Laura McIlvaine will follow up directly with Jim Underhill.
Question 5b: Will HA0 comments included on the DMEPOS claim indicating that the
beneficiary has been discharged allow the claim to process?
The initial request from the home health agency sets up an episode for a period of 60
days. If a DMEPOS claim is received within that time frame, the claim will deny and HA0
comments will not eliminate the denial. Once the final claim is filed by the home health
agency and the episode end-dated, the supplier can refile denied claims.
Question 6: The A-Team requested that CIGNA clarify in a future Dialogue article.
Home Medical Equipment (HME):
Question 1: The A-Team will restructure the question for clarity and resubmit for the next
meeting.
Question 2a: What type of written authorization is required and can if be faxed?
The CSR should provide a fax number and allow it to be sent in that manner.
Question 3a: The A-Team will restructure the question for clarity and resubmit for the
next meeting.
Question 3b: The A-Team will restructure the question for clarity and resubmit for the
next meeting.
Question 5: Suppliers indicated that they have seen audits with "educational direction"
indicating fee schedule amounts are required.
CIGNA clarified that the fee schedule is available on the website. A not applicable (N/A)
indicator should be indicated in Section C of the CMN for those items that do not have a
set fee schedule and that are reimbursed on a reasonable charge method. These
instructions can be found in Chapter 4, page 2, of the new supplier manual.
Orthotics and Prosthetics:
Question 1: The A-Team reiterated a strong interest in developing an informational
relationship with a formal introduction form the DMERC or HCFA staff.
Jim Underhill will determine if this can be accomplished, and, if so, the appropriate
manner.
5
Question 3: The A-Team is drafting a cover letter citing the information required and
requests that Dr. Hoover review it for content.
Dr. Hoover will informally review for input guidance, but emphasized that this review will
not result in an approval for use.
Question 4: The A-Team reiterated the importance of the information maintained in the
CWF and the challenges created for suppliers because they cannot access it prior to
providing service to a beneficiary.
Question 5: Suppliers requested additional clarification on the appropriate coding as
code description is referenced in one portion of the answer, while beneficiary clinical
condition noted in another.
Dr. Hoover indicated that the second portion of the answer was provided for background
on the recent changes. He recognizes that there may be issues with the codes. He will
try to write a Dialogue article on the coding changes.
Question 6: Suppliers reiterated a willingness to continue to work with the DMERC to
provide information that may be helpful.
Rehab:
Question 1: Suppliers question why additional information is not requested prior to
processing on all claims if information contained in the CMN is ineffective to make
coverage determination.
Dr. Hoover will research what other DMERCs are doing in these circumstances, but
indicates that most claims that need CMNs do not develop for additional information.
Question 2: Suppliers questioned whether or not K0097 is a reimbursable code and if
additional specific information is required for processing.
Dolly Baughman would like examples of denied claims for this code.
Previous Issues for Rehab:
Question 1: Suppliers questioned whether the Advanced Determination of Medical
Coverage (ADMC) will provide a solution and if the PIM has clarification of appropriate
action for suppliers to take in this circumstance.
Dr. Hoover indicated that the PIM does not address down coding and will raise this issue
at the next ADMC conference call.
Question 2: Status of further clarification was requested.
Dr. Hoover indicates that the PIM specifies a 90-day limit for CMNs. The suppliers
indicated that a six-month time frame would be adequate for customer wheelchairs,
while 90 days would likely be adequate for other items. Dr. Hoover will follow up with
HCFA. Jim Underhill did not provide an estimated HCFA response time to the question.
6
Education/Communication:
Question 1: When will updated version of Supplier Manual be available on the website?
The website was updated with the new Supplier Manual on April 1.
Question 4: Status of further clarification was requested.
Jim Underhill indicates that HCFA is reviewing the issue. It is not expected to be
resolved within a short time period. He indicates that while Medical Review may not
have issues with scanning, the Fraud and Abuse group may.
7
Region D DMERC Advisory Committee
ACTION ITEMS
March 28, 2001 Meeting
RESPONSIBLE
PARTY
ACTION ITEM
DAC Executive
Committee
Assign DAC representative to attend the CIGNA Spring Seminars
to introduce the DAC and function. The DAC representatives that
will attend the seminars will be forwarded under separate cover to
Dolly Baughman.
Jim Underhill Will provide a list of HCFA representatives that will work with the
respective Medicaid programs to address HIPPA and report at the
next DAC meeting.
Jim Underhill Will inform the DAC of the outcome of HCFA’s review of sections
1.1.1. and 1.1.2. of the Program Integrity Manual and a providers
ability to bill the patient if the conditions laid out in these sections
are not met. (Medical Supplies Question #2)
Laura McIlvaine Related to Medical Supplies Question #5a, Laura will provide Jim
Underhill with additional information needed to effectively answer
the question.
HME A-Team Restructure Questions #1, 3a, and 3b for clarity and resubmit for
the next meeting with CIGNA.
Jim Underhill Will determine if the O&P A-Team can form an informational
relationship with the HCFA Alpha Numeric Workgroup.
O&P A-Team Complete sample letter to be used by O&P providers informing
physicians of medical documentation to be included in the
physicians’ records. Provide the sample letter to Dr. Hoover for a
review of the contents.
Dr. Hoover Write a DMERC Dialogue article clarifying coding issues related to
new O&P "Contracture" codes.
Dr. Hoover Research how other DMERCs are handling payment of Power
Operated Vehicles (POVs).
Rehab A-Team Provide examples of denied claims for procedure code K0097.
Dr. Hoover Follow-up with HCFA to determine the length of time a CMN is
valid prior to the service being rendered by the provider. Request
made by Rehab A-Team to extend the CMN window beyond 90-
days.