Reopening Process Overview

Under the Demonstration, the QIC is also conducting analysis of previously completed unfavorable reconsideration decisions to identify potential appeals that are pending an ALJ assignment at OMHA and can now be resolved favorably through the reopenings process. Appeals that have been closed unfavorably by the QIC and that are still within the 60 day time period to further appeal to the ALJ may also be eligible for reopening under this Demonstration, in some instances.

The reopening process will benefit the supplier by identifying appeals that were previously found unfavorable and resolving them favorably in a timely manner.

If a case is identified for potential reopening and additional documentation is required, MAXIMUS Federal will send the supplier an additional documentation request (ADR) letter. The supplier will have 30 calendar days to provide the requested documentation. This request will include specific details about the information required. Once the information is received, it will be reviewed to determine if the requested information is sufficient to support a favorable outcome through this process. If appropriate, MAXIMUS will work with OMHA to have the appeal remanded back to the QIC, the appeal will be reopened, and the supplier will be notified of the favorable decision.

Further, MAXIMUS will assist suppliers in submitting withdrawal requests to OMHA when, through the course of the Demonstration activities, the supplier determines that it no longer wishes to continue pursuing appeal(s) currently pending at OMHA. The supplier may notify MAXIMUS Federal, and reconsideration staff will assist in in this process.

Medicare Durable Medical Equipment (DME) Appeals