REGION D DAC
MEETING with CIGNA - MINUTES
Wednesday, October 30, 2002
Georgia World Congress Center
Atlanta, GA

DAC Attendees:
Reid Bellis Deanne Birch Andy Boesl Kim Brunnett
Evan Call Dale Cleveland Mary A. Collins Colin Cooke
Cindy Coy Deborah Davis Colleen DeSantis Rick Graver
Carol Green Velma Goertzen Syd Gubin Chuck Gunther
Sarah Haines Jim Hanton Mike Hayden Wade Hendrickson
Zena Jacobi Kay Johnson Daniel Jurovich Janna Jurovich
Herb Langsam Connie Lind-Fraher Derek Lovesee Laura McIlvaine
Joe McKnight Therman Noville Troy Paz Rich Pozesky
Leslie Rigg Kimberlie Rogers-Bowers Sheila Showalter
Pat Spanel Maria Spencer Barb Stockert Val Taylor
Judy Thompson Angie Waddell Paul Webber Rosalie Webber
Tim Zipp
CIGNA Staff:
Robert Hoover, M.D. Doran Edwards, M.D. Dolly Baughman
Carla Cerchione Barbara Douglas Doug Frazier
Mary Rheineker Amanda Zumwalt
I. General Business
Introductions conducted. The minutes of the September 20, 2002 meeting were approved as
submitted.
II. Medical Director Update – Dr. Hoover
a. PCOM Advisory Group
Dr. Hoover summarized a new committee that was formed known as the Provider
Communication Advisory Group (PCOM). PCOM is an open to physicians, beneficiaries, and
DMEPOS providers that focuses on educational training issues with the DMERC. He announced
that Doug Frazier has been chosen as the Chair for PCOM.
Dr. Hoover reported that he has reviewed the focus of the PCOM with Wade Hendrickson and
solicited the Executive Committee’s opinion. He reviewed a letter written to the DAC on the
issue. He also noted that due to the specific focus of the PCOM he did not feel that it replaces the
DAC’s Education A-Team or did it set a precedence that could eliminate the DAC. It is to meet
CIGNA’s contractual obligation with CMS.
b. Upcoming bulletins
It was reported that the December DMERC Dialogue will have a new format and will include
new codes and new modifiers.
The CIGNA website will have a new format with improved user-friendly policies and an
improved search engine. The 2003 Fee schedule is available on the CIGNA web site. A live
crosswalk will also be available as a result of changes from HIPAA.
The DAC asked for clarification on whether manual and policy changes sent in electronic format
are considered the "official" policy. CIGNA indicated that no matter how the information is
distributed the last published is the "official" policy.
CIGNA encouraged provides to sign up for the ListServ. They reported that the list serve is being
improved to expand the amount of information distributed electronically. CIGNA is currently
testing to see if the information can be distributed more efficiently electronically. In the future
the list serve will include LMRP notices and manual updates.
CIGNA reported that as of October 2002 they would no longer be required to send hard copies of
the DMERC Dialogues or manual updates.
Dolly Baughman reported that the amount of Webinars would be expanding. Shortly after the
first of the year CIGNA hopes to have Net Courses available. Topics will be maintained on the
website so providers can repeat as desired.
c. Provider Satisfaction Survey
CIGNA will begin sending provider a 2-page satisfaction survey within the next 4-6 weeks. The
surveys will be sent randomly to providers with high denial rates. Will list resources that
providers can use to improve their billing as part of their education process. The survey will
focus on providers’ experiences with CIGNA Medicare.
III. Oxygen Policy Review Update: Dr. Hoover
The DAC inquired about the status of oxygen Local Medical Review Policy (LMRP). Dr.
Hoover indicated that it is still being reviewed, but not been completed due to workload issues.
He reported that he is currently working on three projects the oxygen LMRP, Wheelchair
Accessories K1008s, and the wheelchair seating policy.
The DMERC Medical Directors and the SADMERC, along with the Rehab Assistive Technology
Council of North America (RESNA), are working to establish new wheelchair accessory codes.
These will likely be out by summer 2003.
Dr. Hoover further indicated that the wheelchair seating policy is being handled as a top priority.
The policy has been rewritten and will be re-released for comment. However, at this time he does
not have time frame for the policies release.
Medical Director’s Conference Call Schedule
Dr. Hoover discussed how the four regional medical directors maintain consistency by meeting 3-
times per week via teleconference. The Directors promote consistency by sharing their Q&As
before they are returned to the DACs.
IV. PET (Provider Education & Training) Issues – Dolly Baughman
Dolly Baughman reported that the Medicare Safari seminars are going well. She indicated that the
DAC representation received good comments. One of the main topics CIGNA received questions
about was the KX modifier. The ANSI reason code denials were also discussed. Doug Frazier is
compiling all questions from the Medicare Safari, which some will then be posted in the DMERC
Dialogue or on the CIGNA website.
Ms. Baughman also discussed upcoming topics of the Webinars, the upcoming Net Courses,
which will include a CMS 1500 education course. She further emphasized the need for providers
to sign up for the List Serve.
Carla Cerchione provided a follow-up to a question that the DAC had at Medtrade Spring with
respect to provider’s ability to use of credit cards to register for Medicare Education Seminars.
She indicated that CIGNA is trying to resolve a technical issue that will allow providers to use
credit cards to register on-line. CIGNA hopes to resolve this issue by the next set of seminars.
V. HIPAA Migration
Amanda Zumwalt reported that CIGNA is currently testing software vendors for HIPAA
compliance. List serve participants frequently receive updates on ANSI approved vendors. It is
also available on CIGNA’s web site.
VI. Clarification of Information Sharing
There was discussion about electronic distribution of bulletins, policies, and manual updates.
CIGNA indicated that CMS feels that all providers should have access to the Internet. If not in
the facility they can go to the library. For the company that has paid a subscription to receive the
supplier manual CIGNA does not have to refund the money since it is now only available on the
web. Chuck Gunther suggested that through the provider enrollment process that one of the 21
supplier standards should be to have a PC.
CIGNA is exploring the idea of providing publications via a CD mailing rather than hard copy.
Getting approval from CMS. They will attempt to include all back issues of the DMERC
Dialogue, Supplier Manuals, etc. on a searchable CD. Will communicate this if available.
As a result of this discussion the DAC and CIGNA exchanged the following question and answer:
Question: Which is the official policy and guideline, printed or electronically
distributed? When is the actually effected date of items posted on the
website?
Answer: If posted on the web site take it as the official information. The effective
date is the date the item was posted on the Web Site or the date of e-mail.
Question: Is the exchange of information and clarification of policies as a result of
CIGNA’s communication with the DAC being shared with CIGNA
CSRs?
Answer: They are correcting the process to be consistent. CSRs have a 6-month
training period and then supervision on the telephone for a period of
time. Supervisors back up phones when CSRs receive training.
Dr. Hoover has started attending the CSR’s monthly training meetings. If
information is inconsistent get in writing or talk to the supervisor and get
their name. He uses information from the Q & A as part of his updates
during the training meetings.
The DAC was informed that CIGNA uses several sources for product
training and tends to use manufacturer’s representatives. Manufacturers
meet with Dr. Hoover before doing providing product training to the
CIGNA CSRs. They are prohibited from mention their specific product.
VII. A-Team Leaders review answers provided by CIGNA
Rehab A-Team ADMC Questions
Question: What does a provider do when the manufacture does not utilize product
numbers?
CIGNA: Order forms/price list are accepted as sources in place of the above referenced
material. Dolly requested examples of cases where customer service asked for more
information.
Question: Why is there not a way to assign a case number to ADMC packets of data or
other means to control the documents at CIGNA?
CIGNA: There may be a way to do this. We will consider your suggestions.
Val: Thank you for the consideration of the request, what might the time line is for
implementation, can the DAC be of assistance in the process?
Dr Hoover: CIGNA knows this is a problem, they know what the DAC wants not sure
how to address the issue.
Question: Dealers have reported difficulty with claims where a power tilt system is
provided after a manual recline, they have been denied as same or similar.
CIGNA: Suppliers should provide medical justification for the additional features of
power tilt versus manual recline only. There must be justification for the power versus
manual features.
Question: Instances were noted where an item is determined to be of medical necessity
in the ADMC process, however the item is denied when supplied and billed with a PR-
50, (not medically necessary).
CIGNA: Medical review is revising their process for entering ADMC CMN information
into the system to address this situation.
Val: How might the DAC provide assistance, what is the time line for this revision?
Where is Cigna in this process?
Question: There has been instance’s where the codes have been changed from those on
the CMN/ADMC or additional codes have been added. Do we bill as changed or noted
on the ADMC?
CIGNA: When the code shown on the ADMC response letter is different than the code
shown on the CMN provided with the ADMC request, we intend that you use the code
shown on the ADMC request on the claim.
Question: A power wheelchair is covered if the patient’s condition is such that the need
for a power wheelchair is greater then 6 months. Does this refer to the purchase only and
shouldn’t short-term rental be allowed?
CIGNA: Dr. Hoover will discuss the issue with the other DMERC Medical Director’s to
allow a shorter period of need.
Val: Would you please notify the DAC when the change is implemented, and might we
suggest, greater than or equal to 6 months purchase the item, if less than 6 months allow
the rental of the item.
HME A Team:
The HME A-Team asked for further clarification to question 2 – a. CIGNA indicated that faxes
are being used to clear back logs. They further indicated that suppliers might receive phone calls
from CIGNA requesting information by fax. However, Medical Review does NOT use faxes.
Medical Supplies A-Team
Dr. Hoover indicated that question No. 11 regarding potential conflict between the Paperwork
Reduction Act (PRA) and routine requests for additional information. He indicated that this
question has been forwarded to CMS. Once clarification is provided he will communicate with
DAC Executive Committee.
Orthotics & Prosthetics A-Team:
The Orthotics and Prosthetics (O&P) A-team thanked Cigna/Medicare for resolving the Ocular
previously submitted question, which will now allow two cleanings per year.
CIGNA was asked to provide further explanation regarding question were items are being
coded/descriptions given that are brand specific/to narrow. We were told that if it was made by
several manufactures and not a singular manufacturer that we should see improvements on this in
the winter release. Per the O/P A-Team leader, he has reviewed the winter release and said they
are much clearer and feels it is resolved.
The DAC also addressed further the resources used while making product/coding decisions. Dr.
Hoover indicated that he uses AOPA, manufactures, consultants, and the DAC A-Team for a
resource, but also felt that we may bring more data and will look to use us more in the future to
have a broad base of information.
The Question of the deletion of code 61 was something that CIGNA wished to check into and
Mary Rheinecker is the CIGNA contact for this issue.
Follow-up provided after the meeting on 1/9/03 provided by Mary Rheinecker:
POS 61 - Comprehensive Inpatient Rehabilitation Facility: We have received
confirmation from CMS Central Office that these have a PPS rate that includes DME,
like acute care hospitals. DME provided to CIRF inpatients should not be billed to
DMERCs.
Lastly, the TLSO question was expanded on to say that after the initial brace was supplied, if in
the future the patient needs another brace then the provider needs to use the replacement
modifiers in order to receive reimbursement.
Respiratory A-Team:
Discussion of CIGNA’s response to question No. 15 regarding coverage of Bi-Level to patients
with morbid obesity was expanded. Dr. Hoover indicated that CIGNA would consider reviewing
such coverage, but clinicians need to send supporting clinical information.
Education A-Team:
The Education A-Team asked for further clarification to question No. 20.
Question: What exactly are the requirements on the suggested form?
Answer: On audit an HME was held to the suggested form which has the HIC# on assignment.
After further discussion of a specific issue, CIGNA/Medicare asked for examples. Maureen
Hanna will provide these examples. CIGNA will provide feedback directly to the Education ATeam.
Rehab A—Team
Additional questions:
Difficulty with codes with Medicaid
C015-C051
The DAC asked for clarification on how to determine the salvage value of a custom fabricated
wheelchair made for a beneficiary who expires before delivery. Is 70% appropriate? CIGNA
indicated that they would work with pricing department to get an answer.
Follow-up provided after the meeting on 1/9/03 - The DMERC does not have a set
percentage amount assigned to DME. It is at the Carrier's determination on a case-bycase
basis.
The meeting adjourned.

Region D DMERC Advisory Committee (DAC)
Meeting with CIGNA Medicare
January 30, 2002
9:00am – 11:00am (PST)
Via Conference Call
MINUTES

PRESENT
Region D DAC Representatives:
Laura McIlvaine, Chair
Reid Bellis Deanne Birch Dale Cleveland Vince DeStigter
Rachel Eller Kim Frushon Velma Goertzen Syd Gubin
Chuck Gunther Diana Guth Maureen Hanna Mike Hayden
Wade Hendrickson David Hosman Mary Jackson Kay Johnson
Janna Jurovich Connie Lind-Fraher W.B. Mick Sharon Nichelson
Troy Paz Gloria Peterson Rich Pozesky Carlos Reyes
Kimberly Rogers-Bowers Martin Szmal Val Taylor
Paul Webber David Williams
Center for Medicare and Medicaid Services (CMS):
Jim Underhill
CIGNA (Boise):
Dolly Baughman Carrie Brown Carla Cerchione Doug Frazier
Melissa Hansen Lisa Fix Amanda Zumwalt
CIGNA (Nashville):
Robert Hoover, M.D., Medical Director
Barbara Douglas Kim Largent Anne Love Tricia Luna
Mary Rheinecker Shelly Tant
I. Role Call
Gloria Peterson conducted the role call. Laura McIlvaine briefly reminded participants of
the meeting structure.
II. Comments from Dr. Hoover
a. Local Medical Review Policy (LMRP) Meetings
Dr. Hoover described the process for deciding on the meeting location. He indicated
the following factors are considered during the decision process:
��Cost to the program;
��Locations suggested by the DAC;
��Southwest Airlines destination;
��CMS office available; and
��Dr. Hoover can travel to and from in one day
Dr. Hoover explained that out of the three locations suggested by the DAC, only
Kansas City, MO met all of the aforementioned criteria. He has given thought to
expanding the options by utilizing a supplier facility as suggested by the DAC.
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However, he has decided against this option 0 because it would give the appearance
of impropriety. He continues to explore other options, but Kansas City, MO remains
CIGNA’s location of choice at this time. Dr. Hoover also indicated that he was
pleased with the number of participants at the January 16 public meeting.
CIGNA is also exploring the idea of teleconferencing future LMRP meetings. The
draw back to this format is that providers could not interact and provide testimony
via teleconference.
Dr. Hoover stressed the importance of commenting on draft LMRPs. All comments
are taken under consideration. He reported that DMERCs send draft LMRPs to over
100 different organizations that include provider and beneficiary organizations in
their effort to solicit comments from a wide range of groups in the healthcare
industry.
b. April 2002 DMERC Dialogue
Dr. Hoover indicated that the April 2002 DMERC Dialogue will contain a large
amount of important information. Full chapters of the DMERC Manual will be
updated in this issue. Also the following important notes: 18 policies will be
republished, HCPCS codes will be updated, important modifier changes will be made
to comply with HIPAA, and the CPAP policy update will be published.
Dr. Hoover explained the CPAP policy dates as follows:
4/1/2002 and after CPAP national coverage decision takes effect.
4/1 – 7/1/2002 No Local Medical Review Policy in effect.
7/1/2002 and after New Local Medical Review Policy in effect.
III. Common Working File Access
Wade Hendrickson addressed Jim Underhill on providers’ access to the Common
Working File. Mr. Hendrickson ask Mr. Underhill to comment on a recent CMS press
release that reported major systems upgrades that would allow edits to be put in place that
would allow providers access to the CWF.
Jim Underhill indicated that there are not enough details available on how these systems
changes will work. He acknowledged that with this notice CMS has definitely taken the
first step towards allowing access to the CWF. However, the provider community needs
to wait for further details to be provided.
ACTION ITEM The CWF should be a standing agenda item per Jim Underhill’s
request.
ACTION ITEM Wade Hendrickson will forward the notice on the CMS systems
upgrade to Jim Underhill.
Troy Paz asked Tricia Luna to provide an update on the Internet project. She indicated
that it is still currently under development and she will continue to keep the DAC
informed of its progress.
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IV. CIGNA Provider Relations Update
Dolly Baughman reported on two formats under development that will allow providers
access to on-line computer training. Webinars will be Internet and/or telephone based 60-
minute focused training sessions that will allow for some provider interaction. The first
topics will be ABN upgrade and completing a HCFA 1500 form. Net-Courses are pre
developed mini courses only available on the Internet. The first topics will be the basics
of EDI. These courses will be self-directed and will be available this spring.
Ms. Baughman indicated that there will be no Spring seminars in 2002. The Fall
seminars are being developed and will be held in 26 locations. They will cover the new
CPAP policy as part of the fall seminars; however, they will not be able to include the
new wheelchcair seating and revised oxygen policies as suggested by the DAC. The
Spring seminars will resume in 2003 and CIGNA plans to cover these policies at that
time.
Dolly reported that ANSI code denials and modifiers will be included in the Fall seminars
with HIPAA and EDI. She also summarized CIGNA’s schedule at Medtrade Spring in
Las Vegas, NV.
V. ADMC, BGM Diabetic Supplies, and Upgrades
a. ADMC
Dr. Hoover asked the DAC to provide feedback on the ADMC process. Val Taylor
reported that the initial ADMC process has been very smooth. However, suppliers
have not had enough time to follow related claims through the payment process to
determine if claims will pay correctly. Jim Underhill asked that suppliers monitor
how this process is working so that any issues can be resolved.
Val Taylor reported on the call that he has one claim that has been through the
ADMC process and for which he received only partial payment. He will provide Dr.
Hoover with details. Dr. Hoover gave Catherine Marlin's at (615) 782-4500 x28812
as the contact for this information.
ACTION ITEM Include ADMC as a standing item on the agenda per Dr.
Hoover and Jim Underhill’s request.
ACTION ITEM Val Taylor will work with Dr. Hoover to follow an
ADMC claim through the payment process.
ACTION ITEM Rehab A-Team will continue to monitor the ADMC
process and provide feedback and examples for any
questions sent to CIGNA for our April meeting.
b. BGM Diabetic Supplies
Shelly Tant reported that effective for dates of services beginning 4/1/02 all diabetic
test supplies will require beginning (From) and end (To) dates. Also, beneficiaries
will no longer be allowed to submit their own claims, it will be mandatory for
suppliers to file these claims.
Ms. Tant reported that the date of service (DOS) "from" date is the date the test strips
were shipped to the patient. Providers will calculate the "to" date by taking the
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number of strips provided divided by the number of strips the patient is to use per
day.
Laura McIlvaine asked if the "to" dates can overlap with new "from" dates. Ms. Tant
indicated that claims with dates that overlap but do not have matching From dates are
acceptable.
Maureen Hanna indicated that some of her clients that have started using the span
dates are experiencing denials when the "to" and "from" dates overlap. Mary
Rheinecker indicated that CIGNA would look into this problem that is believed to be
a result of a Common Working File (CWF) edit.
ACTION ITEM Sharon Nichelson will include this issue on the next
Medical Supplies A-Team agenda for follow-up at the
April meeting with CIGNA.
c. DME Upgrades
Ms. Tant stressed the importance of suppliers following CIGNA’s specific
instructions when billing for upgraded DME items. Maureen Hanna indicated that
some suppliers are are unable to bill electronically in the required two-line format
because their billing software does not allow two separate claim lines for one item.
This issue is forcing providers to manually submit claims. Dave Hosman indicated
that many software vendors are willing to make the appropriate changes, but will not
do so until after 4/1/02 in case there are changes in the requirements in the interim.
ACTION ITEM The Education/Communication A-Team will work on
this issue to provide further feedback to CIGNA at the
April meeting.
ACTION ITEM Jim Underhill should be included on any correspondence
to Shelly Tant about the DME upgrades.
VI. Review of Questions and Answers
Medical Supplies
Question #2- This is regarding added editing that will identify paid claims that are within
the Home Health claim dates. Sharon Nichelson asked if that is going to be decided by
the actual claim date or the RAP (Request of Anticipated Payment) date?
CIGNA answered that it would be the actual claim date.
Also, Ms. Nichelson asked if there was a possibility that the DAC Medical Supplies ATeam
could set up a conference call with CIGNA to discuss questions about the new
Program Memorandum regarding K codes for Ostomy supplies. Dr. Hoover stated that
he would send out to the Medical Supplies A-Team a draft bulletin article regarding the
K codes. He asked the A-Team to review the article. If the A-Team still has questions
then they should be submitted in writing. Dr. Hoover will then work with the A-Team to
determine if a conference call is needed.
ACTION ITEM Dr. Hoover will forward the draft bulletin article addressing the
Ostomy codes to the Medical Supplies A-Team.
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ACTION ITEM Medical Supplies A-Team will review the article and submit
additional questions in writing to Dr. Hoover.
Home Medical Equipment (HME)
Question #7 – Kim Frushon asked if there was anything that the DAC could do to help
address Dr. Hoover’s concerns with regard to his assistance in contacting recalcitrant
physicians. Dr. Hoover stressed that it is important for suppliers to exhaust all other
methods before asking for Dr. Hoover’s assistance. He advised that suppliers carefully
consider using this resource.
ACTION ITEM The HME A-Team will work with the executive committee to
attempt to get additional education to the providers via the DAC.
Kim Frushon also asked for Dr. Hoover to address the last part of Question 7, "Would
CMS consider a new prescription process and help organize a provider group to examine
problems with CMN processing and developing an alternative to the present
procedures?"
Dr. Hoover will extend the DAC’s offer to CMS. He indicated that the CMS has
developed the Physicians Regulatory Initiative Team (PRIT) that surveyed physicians to
determine the top 20 items considered a Medicare regulatory burden. He reported that
CMS has determined CMNs to be high ranking among the top 20.
Question #10 – The last question in paragraph one regarding which publication prevails,
whether a 1994 Dialogue article or the 1995 policy on CPAP was addressed. Dr. Hoover
indicated the general rule is that the later publication date generally prevails, however, in
this instance that is not the case.
The A-Team requests that CIGNA update policies as necessary, so that providers are not
tasked with making determinations of what is an exception to published medical policy.
Respiratory
Dale Cleveland requested an anticipated date of oxygen retesting policy. There is no
estimated completion date at this time. Dr. Hoover reported that April 30 is the next
policy publication deadline and their goal is to make that deadline.
Orthotics & Prosthetics
#18 – Additional clarification was requested concerning the substitution of code L5510
for L5502. Dr. Hoover indicated that the April bulletin will include information
specifying which codes included in the policy are not a covered benefit.
Mr. Webber voiced concerns over fact that no reimbursement level had been set. Dr.
Hoover explained the elements necessary for calculating a reimbursement level.
Question asked about concerning certification requirements for L5511. Certification for
custom orthotics and certain prosthetics was in BIPA section 427 and requires CMS
publish a regulation on who is a qualified provider. CMS is in the process of drafting this
regulation.Item #19 Question asked what information was required in order for the
possible inclusion of non-elastic compression garments as Medicare covered benefits.
Dr. Hoover remarked that the manufacturers and the information from the A-Team for
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O&P had provided voluminous records supporting the device but time would be needed
to sift though the acquired information. This question was left open for further
discussion at a later date.
Paul Webber asked about the number of times that Medicare would approve payment for
the polishing of ocular prostheses. Dr. Hoover agreed that this had been a subject matter
that had been neglected by both parties and he would again begin collecting the
appropriate information to base a decision on this matter.
Dr. Hoover was also going to be re-checking the information regarding the titanium peg
as to whether or not this procedure necessitated a new HCPCS code; however, based on
his research to date, he would not advocate for a new code.
Rehab
Question #24 – ANSI denial codes continue to be an issue for providers dealing with
other payers. Jim Underhill agreed to determine if denial codes would be addressed in the
administrative simplifications mandated by HIPAA.
The meeting adjourned.