Present:
Region D DAC Executive Committee Members: Chair: Val Taylor; Secretary: Rick Graver; Treasurer: Reid Bellis; and Past Chair: Rich Pozesky. Administration: Rose Schafhauser.

CIGNA Government Services/Region D DMERC: Doug Frazier, and Kathy Brock.
IntegriGuard/EDS: Dr. Mark Pilley, and Missy Edison, Policy Coordinator.

Region D DAC Participants: see enclosed listing.

Meeting opened at 9:01 am

1. Introductions of all attendees ensued.

2. General Business:
a. Review of meeting protocols: Chair Val Taylor reviewed the meeting protocols.
b. Approval of meeting minutes: A motion to approve the October 18, 2005 meeting minutes as written by Sharon Nichelson. Second by Laura McIlvane. Motion carried.

3. Medical Director: Dr. Mark Pilley:
a. Dr. Pilley expressed that he appreciates the opportunity to work with the DAC. He plans to continue on with the interaction with the DAC and to keep an open line of communication. Their objective is to pay claims right and appropriate and be available to the industry.
b. Nebulizer policy will be released sometime next week for notice and comment. They will have open forums. The dates of the forum have not been set, but should be late April. The forum will most likely be in the Kansas City area and should have a teleconference option. The deadline to comment will be in May. Comments will be accepted through the following email address: draftlcdfeedback@integriguard.org .
i. Dr. Pilley recommended the DAC member’s sign up for list serve under DME Home Page http://www.edssafeguardservices.eds-gov.com/providers/dme/listserv.asp . The policy will be released through the list serve.
c. Make sure to also visit the Program Safeguard Contractor (PSC) website by going to http://www.edssafeguardservices.eds-gov.com .
d. Alphanumeric group is busy working on coding and medical review on claims. They do data analysis on claims for any issues and opportunities for education. Discussed the Comprehensive Error Rate Testing (CERT) program. There are different types of error rates on claims. They do data analysis of trends for product sales. Their objectives are to educate through this process. The CMS Document Center (CDC), an electronic data base, will be sending letters for documentation of further information. This is part of Program Integrity.
i. Challenges may exist between the Medicare Administrative Contractor (MAC) and the PSC. Both entities are committed to make it work.
ii. Region D DAC Chair Val Taylor introduced the concept of the new transition team, formally the ADHOC committee that will work together with the respective entities.

4. Medicare Beneficiary Information – Provider Access: Rick Graver provided background information regarding the issue on the same/similar denials. The goal was to identify better ways to address this issue. The DAC developed a white paper on a more efficient way to verify same/similar equipment for the beneficiary. Currently the only was to access the common working file (CWF) is on a 3 way call with beneficiary.
a. Dr. Pilley responded that there is no pre-certification except for the ADMC program for certain equipment. This is not an easy answer. He suggested sending the request through contractor and CMS. Doug Frazier sends the meeting minutes to CMS. This issue will continue to be addressed.

5. POE Update: Doug Frazier reported on the following:
a. Spring Seminars are being conducted. The seminars are called "Medicare, a New Beginning". They will discuss the Medicare Contractor reform, claim submission, orders, medical records, modifier usage - KX modifier goes to adjustments, and changes to the appeals process. The seminars start in April. CIGNA did not send mailers, so only online registration is available. You are now able to pay with a credit card. The DAC is invited to talk.
b. Webinars are on hold.
c. Net Courses: now up to 25 courses. New one on CMNs.
d. CR4376 Suppression of Standard Paper Remittance Advice to Providers and Suppliers Also Receiving Electronic Remittance Advice for 45 Days or More: As of June 1, 2006 remittance advices will only be electronic, and will no longer get paper. This will be effective for billing services as well. CMS is going away from paper. CIGNA has rolled in a Net Course on Remit Software program. Brochures are available. Electronics Funds transfer may be mandatory.
e. With uncertainty in the future of who will be the DME MAC, Doug Frazier indicated that as an organization, the Region D DAC needs to stay strong. He thanked everyone for the opportunity to work together. It has been a pleasure.

6. New Business:
a. Flow of information. Sharon Nichelson reported that the Region D DAC Orthotics and Prosthetics A-Team had worked on pricing for L codes that were created for PT/OT codes. They had worked with Barbara Douglas and CIGNA. She is not sure of the status of it.
i. Response: Dr. Pilley recalled seeing something on this. He is not aware of the status and will find out. He meets frequently with the group.
b. CPAP LCD/NCD: (LCD ID NUMBER L171 issued 3/1/06) Joe McKnight reported on the discrepancy on minimum requirements for sleep study - specifically, the change in language in the appendices that indicates that the AHI is determined by 2 hours of sleep time rather than 2 hours of recording time as printed in the previous LCD's. Moreover, the latest version of L171 notes in the "other comments" section that "Revised the definition of AHI to require a minimum of two hours of recording time without use of the device rather than 2 hours of sleep time". The question is how to eliminate the confusion that exists within the LCD and why was the language changed.
i. Response: Dr. Pilley responded that it should reflect NCD. The LCD is written based on NCD and is used to further explain the NCD. The language in the NCD requires 2 hours of sleep. The LCD has 2 hours of required sleep time. Dr. Pilley will bring this up for further discussion. The LCD has to reflect NCD. 2 hours of recorded time does not exist - it is 2 hours of recorded sleep time. Dr. Pilley stated that he didn't see any difference between sleep time and recording time. Question of Dr. Pilley if this may change? He responded that he will discuss with the other entities and will provide clarification in some form. The DAC also requested to share this clarification with sleep doctors.
c. White Paper on BIPAP ST change in payment category: The DAC has written a white paper on this issue that we would like to have reviewed and will be sent to CMS, and the PSC.

7. A-Team Leaders:
a. EDI/EMC: There were no further questions.
b. Education/Communication/PCOM: There were no further questions.
c. HME:
i. Question # 3: A-Team Leader Barb Stockert asked that on written orders to please clarify "electronic" written orders – is it an email?
1. Response: Doug Frazier responded yes it is as long as it has all the requirements for the written order. CMS has not clarified the signature issue. As long as the signature is notated in patients file. Dr. Pilley added that when you get orders by email, this may be an un-secure communication – for it includes personal health information - and would be a violation of HIPAA. Fax and mail orders are the best. Be cautious about email processing.
a. Question: What if it was an encrypted email that is secure?
b. Response: Can't really answer. CMS has some issues with it.
ii. Question # 4: Please re-explain first part of the answer in regards to the new supplier. Barb presented an example of a provider had billed in error, had done a pick-up, and refunded the money. Now the provider will be providing equipment again. The DMERC customer service representative told them how to handle it.
1. Response: Doug Frazier indicated that an exception is if there is no one else to service the patient, this can be done. Make sure to document in your files that this is the case. However, the provider will not get paid for previous service. It would restart the clock for capped rental.
a. Barb asked where this would be documented in writing. Most of the team members understood the policy to read that if we provided an item that required a WOPD and we found out that we did not have this -- but before a claim was submitted.  We could do a pick up, get a new prescription, and redeliver the item.  We did not think that it had to be provided by a different supplier.  What we wanted Doug to clarify was where in writing it stated that we could never provide and bill for this item?
b. Response: this is not in writing. Doug will check if there is something available to address this scenario.
d. Infusion Therapy: There were no further questions.
e. Medical Supplies:
i. Question # 9: Assistant A-Team Leader Mary Turner asked for further clarification in situations where the provider is not always aware the beneficiary is in a HHS/PPS episode even though they are asking the question.
1. Response: Doug Frazier responded that the provider can bill the HHS or SNF, and if they will not pay, can bill the patient. In early 2005 in a Change Request it was clarified that if a beneficiary is in a SNF PPS and you are providing services you have to get a written agreement to get paid from the SNF.
a. Mary asked if the document exists between supplier and a HHS/SNF, how do we get that information.
b. Doug said at this time there is no way around this.
c. Mary responded there used to be a form that could be used and was hoping for reinstatement.
d. Doug will research this and look as to why this was taken back.
i. Mary will do another white paper on this issue.
ii. Question # 9 - letter E: How do we go about this?
1. Response: Doug Frazier indicates there is not anything at this time and suggests including this in the white paper.
iii. Question # 10: In regards to an ABN for same/similar, the term "genuinely" used in the response is vague.
1. Response: Most providers may have an idea, or if there is a question in your mind, make sure to get an ABN.
a. What documentation should be used?
b. As long as the reason on ABN is sufficient to inform the consumer that they may be responsible. Something like "It is our belief that you have had this equipment before..."
i. Mary responded that she will do a follow-up question in writing about being able to bill the patient if the SNF/HHS won't pay.
f. Orthotics & Prosthetics: There were no further questions.
g. Rehab:
i. Question # 15: A-Team Leader Leslie Rigg indicated that providers are continually having a problem with the coding and matching the equipment. She acknowledges that this is under discussion and looks forward to an additional response.
1. Response: Dr. Pilley reported that Dr. Doran from the SADMERC is continually working on this. There will be a breakout on weights. It is in process to move forward and wrap this up, but he does not have a date.
h. Respiratory:
i. Question # 16: A-Team Leader Yvonne Cordoza stated that providers understand the right to request further documentation. However, they do not understand why the claim is suspended for so long to get information. Would like further explanation on the hold up.
1. Response: Dr. Pilley responded in the case of nebulizer drugs, if the beneficiary needs the level of dosage that is more than allowed it goes to medical review for further documentation.
a. Why can’t the DMERC pay the allowed amount and deny the rest, because it holds up payment on the whole claim when it goes for development. Then the provider would review the additional dosage with the clinical documentation for the medical need.
b. Response: Doug Frazier indicated that CMS changes edits all the time. He thinks that edit changes are in place to stop these claims from being processed.
i. Is there a way for a provider to stop this?
ii. Response: Doug feels there is no way to stop this. He suggested it be a question for CMS.
1. Dr. Pilley indicated they did not know and will follow-up on this issue.
ii. Question # 17: Request for clarification when a doctor is attesting the further need for oxygen because a beneficiary is unable to make it into the doctor’s office because they are bed ridden.
1. Response: Dr Pilley said this is an issue in all regions. If you are provider, and you submit claims, in support of doing testing in the home. A home health nurse does the test; the results should be able to be used by the doctor. Doug Frazier clarified that if the test is able to billed, it then could be used in the report. If the test is not able to be billed to Medicare, it will not be able to use the report.
iii. Question # 18: Received different responses on this. Need more clarification in regards to the test being done on same day.
1. Response: Dr. Pilley reported that when a doctor is testing in their office, there should be oxygen in the office. However, this is not a requirement. When the beneficiary exercises and they desaturate, the payment should be justified. Blood gases takes precedent, but all doctors don't have it. It is written the way it should be performed. It is important to do the tests on the same day.
a. Nowhere is it written in the policy that it must be on the same day.
b. Doug responded that when they have conducted training in seminars, they have received response from medical review that it needs to be on the same day. It is not in the policy and Dr. Pilley states that it should be in the NCD.
i. Other Issues: Are the ADMC and medical reviews going to the PSC/IntegriGuard? Had received discrepancies that the PSC was not doing the ADMC.
i. Response: This was an error in their communication. ADMC and medical review transfers from CIGNA on March 1. And if not determined by March 1, forwarded from CIGNA.

Present:
Region D DAC Executive Committee Members: Chair: Val Taylor; Vice Chair: John Kenney; Secretary: Rick Graver; Treasurer: Reid Bellis; and Past Chair: Rich Pozesky. Administration: Rose Schafhauser.

CIGNA Government Services Region D DMERC: Ellen Edenfield and Barbara Douglas.
DME Medicare Administrative Contractor (MAC) Noridian Administrative Services (NAS): Teresa English and Janet Kirsch.
Program Safeguard Contractor (PSC) IntegriGuard/EDS: Dr. Mark Pilley, Carrie Metzke, Amy Barnes, Carolyn Osborne and Missy Edison.

Region D DAC Participants: see enclosed listing.

Meeting opened at 11:01 am

1. Introductions of all attendees ensued and a reminder of the protocols were read.

2. General Business:
a. Approval of meeting minutes: A motion to approve the March 22, 2006 meeting minutes as written by Wade Hendrickson. Second Sharon Nichelson. Motion carried.

3. Medical Director update: Dr. Mark Pilley:
a. Very active year: Final rule for Power Mobility Devices has been put out with dropping of CMN and inclusion of a face to face within 45 days from the time of the order. In the process of completing draft policy and implement the LCD that will be coming out in the near future. A bulletin article on the documentation requirements and ADMC will also be done. Codes for wheelchairs will also be coming in the future, most likely on 10-01-06.
b. CMN changes: updating the LCD and articles on those items that are affected in the changes in CMNS and DIFs. This may also happen 10-01-06.
c. Nebulizer policy still remains in draft form. The policy is still in review and consideration of the thousands of comments they have received.
d. Transition update: March 1, 2006 the PSC went to EDS/IntegriGuard. Noridian Administrative Services (NAS) will be the claims processor. The DME MAC transition to NAS will be Oct 1, 2006.
i. Questions: Val Taylor asked about the request in the NAS newsletter for members of the Provider Outreach and Educational (POE) Advisory Group, if this is the same as the PCOM?
1. NAS responded that it will stay the same and will move over to them. The previous membership, along with new members, will now be called the POE. Only the DME MACs will have the POE.

4. Medicare Beneficiary Information – Provider Access: Lori Borelli was not on the call.

5. CIGNA Update: Kathy Brock and Doug Frazier were not on the call.

6. New Business:
a. Next meeting at Medtrade: Discussed having the meeting at Medtrade on Tuesday, September 19 ^th , 8:00am to 10:00 am for the DAC only meeting, and the DAC/DME MAC/PSC meeting from 11:00am to 1:00pm. The DAC office is setting up the room. We will send the dates and times to the respective entities to see if this will work.
b. Equipment Fair: Val Taylor asked both the PSC and the DME MAC if both are still interested in having an Equipment Fair. The PSC is still very interested. Val explained the workings of the Equipment Fair where there would be all the various grouping of items; the HCPCS it represents; and able to ask questions. Each staff member would be able to go through the fair if we held close to the respective offices. It is a separate from Medtrade. The DME MAC will discuss this internally and let us know. They would not want to do the Fair during the transition time.
c. Other New Business: The NSC A-Team did not have questions, but did want clarification on diabetic shoes. Wade Hendrickson discussed if there is an update to report on as to what other healthcare provider can provide diabetic shoes. Has anything changed in this for it was rumored that Dr. Pilley had been looking at defining further.
i. Response from Dr. Pilley: nothing has substantially changed since the previous clarification. There is discussion as to what licensed certified professional means. It is under discussion and consideration and no decisions that have been made. Provide language that they are certified to provide the services. There is discussion on a national basis, but there is no time frame. If there is substantial change, then that would require it to go to a comment and notice period.
1. Question: Wade asked if there was an entity, like an association who developed a program, how does that program get included and who would they get the information to?
2. Response from Dr. Pilley: those policy changes would have to come out for comment, and at that time they can make a request to be included. There is the option now for reconsideration of a LCD. There will ample opportunities to make a request.
a. Question: Wade asked if we have already utilized that time and the request a few years ago. He asked Dr. Pilley to get back to us if this time frame hasn’t already come and gone.
b. Response from Dr. Pilley: it is in current discussion for making changes and he is not familiar with what transpired a few years ago. Send request to him to forward on this question for consideration and he provide response back.

7. A-Team Leaders review of questions: See separate question and answer document.

Meeting concluded at 12:18 PST – (1:18 MST, 2:18 CST, 3:18 EST)

Present:
Region D DAC Executive Committee Members: Chair: Val Taylor; Vice Chair: John Kenney; Secretary: Rick Graver; Treasurer: Reid Bellis; and Past Chair: Rich Pozesky. Administration: Rose Schafhauser.

DME Medicare Administrative Contractor (MAC) Noridian Administrative Services (NAS): Janet Kirsch.

Region D DAC Participants: see enclosed listing.

Meeting opened at 11:06 am EST

1. Introductions: Chair Val Taylor opened the meeting with introductions of all attendees and reviewed the meeting protocols.

2. General Business:
a. Approval of the meeting minutes from July 12, 2006: A motion to approve the meeting minutes as written by Laura McIlvaine. Second by Wade Hendrickson. Motion carried.

3. Medical Directors Update:
a. Dr. Mark Pilley was not available and therefore no update was given.

4. Medicare Beneficiary Information Provider Access/Same/Similar: Lori Borelli communicated with the DAC office that no one from CMS was able to attend the meeting. CMS is aware of the white paper and the DAC will continue to pursue.

5. Noridian Administrative Services (NAS) Update: Janet Kirsch reported on the following updates:
a. Handouts from NAS were discussed that will be helpful for providers. Contact information such as web site, email and other helpful contacts was one of the handouts. The information is also on the web site.
b. NAS will be taking over September 30, 2006.
c. Go onto the NAS website at www.noridian.com for the latest information and to keep informed of the changes. Visit "What’s New" in the upper right corner. Providers will also want to sign up for email list serve if you did not participate in CIGNA’s list serve. NAS carried over CIGNA’s email list serve. NAS will compile into a weekly email.
d. Communications with suppliers:
i. Ask the Contractor (ACT) teleconferences have been held.
ii. NAS finished the 3 ^rd newsletter. This can be found under News and Publications. It includes key dates for the transition and steps needed.
iii. NAS needs signed Electronic Fund Transfer (EFT) forms: the deadline has been extended, so please send in ASAP. If providers are new to EFT, these will be processed in October.
e. Electronic claims Contractor ID: providers need to change ID from CIGNA to NAS. This information is on website.
f. Express Plus, software from CIGNA: Providers will need an update that went out in August.
g. Dark Days: Friday, 9-29-06 will be a dark day. In addition, a reminder of 9 day payment hold for CMS will be in effect as well.
h. How to contact NAS: If you have questions on the transition, send an email to dme@noridian.com . This email will be used after the transition.
i. The phone numbers have not changed from CIGNA.
j. Addresses: the PO boxes have changed. One of the addresses is for claim re-determinations. Benefit protection forms have a separate address. The EDI address has changed to a Tennessee address. A notice on this went out from CIGNA.
k. Interactive Voice Response (IVR): a new option available will be voice activated. Calls have to be made in a quiet area and do not use a cell phone. Providers should like it. The features will include a status of CMN, and beneficiary eligibility. Additional benefits will be coming in November.
l. Frequently Asked Questions (FAQs) on website.
m. Ask the Contractor (ACT) Calls: updates are provided on the teleconference and NAS will open up the phone lines for questions. The next one for EDI is 10-12-06 at 3:00 central time and will be mainly to discuss how the transition went. The next one for providers is 10-19-06 at 3:00 pm central time. The ACT calls maybe monthly after the transition. The minutes of these calls are on the website. Providers do not need conference ID, but unfortunately the last one did in error.
n. Web Tours: In October there will be training on the website. Information on how to participate will be on the training page.
o. Go to booth 4169 to find NAS.
i. There were no questions on the NAS update.

6. New Business:
a. Next DAC meeting: A teleconference will be scheduled January. The DAC will go ahead and schedule and will let NAS and IntegriGuard know.
b. Equipment Fair: Val Taylor asked when and where NAS would like to schedule the fair. Both the DAC and NAS agreed to schedule in the Spring. The Education A-Team will communicate with Janet Kirsch to schedule.

7. A-Team Leaders review of answers provided by NAS and IntegriGuard:
a. EDI:
i. Question 1): Examples of the ICN were provided to NAS. Once they have access, they will respond accordingly. Update: NAS received details on 11/17 and research is underway.
b. Education: Cindy Coy asked the following:
i. Question 2): In the response that if the manufacturer warranty is not in place, can we bill for repairs or bill the patient and would an ABN be required?
Response: It was asked of the DAC what happens now? NAS feels it would be the same situation going forward. However, NAS will research that further. Update: Repairs will be considered for coverage outside of the manufacturer’s warranty. The usual rules for when an ABN should be obtained would apply.
ii. Question 6): Follow-up question was asked if there are workshops already scheduled.
1. Response: In the spring there will be a series of workshops. NAS will be doing web based education first. The first one will be on the revised claim form which allows for reporting of the NPI.
c. HME: Barb Stockert asked the following;
i. Question 8): Follow-up question was asked on the examples that had been provided on both an electronic Rx and a handwritten RX. The DAC would like confirmation that electronic signed RX is ok?
1. Response: The DME MAC will be following CMS guidelines and therefore it is acceptable.
ii. Question 7): There is a code for the Roll-A-Bout, which on the Medicare website it says it is not a valid code. In the example used, if the equipment has a code, the patient wants it billed to Medicare, what should the ABN say? We have received a denial back stating that the ABN was not valid. The DAC members did not understand the document that was referenced in the answer. This document was directed towards the doctors, not for DME, and it was hard to follow.
1. Response: E0118 is covered by Medicare. Conflict there with the Medicare website. On ABN, the use of "may" not be covered, "may" could be the issue. Excluded from Medicare benefits if it is not covered. We should be using the same coding source. NAS will take it back to determine if the item is covered, what the ABN should say or if not covered. Update: NAS is researching.
a. NAS reminded members of the DAC if you have questions, do not have to wait for quarterly meeting to get response. Call Medicare. NAS is implementing a system when calling in asking questions, the person will research and if they can't answer, it moves to someone else who will be able answer. This is CMS mandated, but not yet implemented. This will change when they transition. The DAC responded that is great, but will not help out other providers who may have the same questions. NAS will also be having meetings approximately every few weeks to review common questions asked.
d. Infusion: Mike Hayden reported there were no further questions.
e. Medical Supplies: Mary Turner asked the following:
i. Question 10): Follow-up to the response that sometimes confusing information that is out there. Mary reported on a letter that IntegriGuard did on Glucose Monitors and what the documentation requirements are. Based on this letter, providers do not need verification that the patient saw the doctor every 6 months, it also does not mention the requirement of copies of the diabetic log book every 6 months. Mary also read the LCD that disputed what the letter said. What is the new required documentation? The letter clearly states that it is intended for physicians and suppliers. Information to physicians and suppliers should be clear and complete.
1. Response: The bulletin was meant for suppliers. IntegriGuard would have to respond to this issue. NAS agreed that they should work to develop a close working relationship with IntegriGuard.
f. O & P: Sharon Nichelson asked the following;
i. Question 12): Letter b. In the answer NAS identify as DME is not covered in a SNF POS. The items is under the O & P benefit and should be covered in the SNF. Is there a code that should be used?
1. Response: NAS will research, will redo the response and get it to DAC central and it will be explained in the updated version of the Q & A. NAS is in the process of formulating the response.
g. Respiratory: Yvonne Cordoza reported there were not further questions.
h. Rehab: Leslie Rigg asked the following;
i. Question 14): In regards to the elimination of notification to the beneficiary of the purchase of the chair. In the 11 ^th to the 13 ^th month claims, is the BP modifier sufficient?
1. Response: CMS has not clarified this. Providers should educate the beneficiary.
ii. Question 18): The answer indicates the wheelchair needs to have a written detailed product description (DPD) and that all separate accessories needs to be listed. Does the DME MAC need each pieces/accessories part number with the manufacturer name number? This becomes and issue when changing accessories on complex rehab products and many time changes are made.
1. Response: It will have to taken back and looked at by the PSC.
a. Example: the beneficiary needs a tray, will a new DPD needed?
i. Response: will need to be looked at.
ii. The DAC emphasized that figuring out of the DME MAC relationship with the PSC is needed for NAS needs to know how the claims need to be processed. This will become an issue when education is being done.
1. Response: before going out to do education, NAS will have to have each both the DME MAC and PSC sign off on the education. NAS also wants to hear from the DAC on examples like this.
i. Other Issues/Questions:
i. The DAC asked NAS if they could explain how the two organizations, the PSC and DME MAC, work together?
1. Response: NAS indicated they the relationship with the PSC is being built and will take some time to determine the exact roles of each party in responding to questions from the DAC. . On the questions submitted by the DAC, both entities went question by question on who was doing what - and in some cases, both were to respond. Both organizations will be communicating on an ongoing basis on who coordinates what. NAS will provide further information as it becomes available. Both entities also worked with CMS as well. At this time, NAS does not know who the main contact at CMS will be or if they have been chosen yet. NAS will let us know when this is announced.
ii. The DAC sometimes is uncertain on some questions being submitted as to when the question would need to be directed to CMS.
1. Response: NAS suggests continuing putting them in the questions and they will help us in this transition.

Motion to adjourn at 12:10 pm.