Having certain Medicare claims re-opened without the appeal process!

Medicare Claim Re-openings and How to Request a Reopening

In the case where a minor error or omission of your Medicare claim submission resulted in a claim denial, you can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. There is no need to request an appeal/redetermination if you have made a minor error or omission in filing the claim, which, in turn, caused the claim to be denied. You can request a reopening for minor errors or omissions either by telephone, in writing or via NGSConnex. You have one year to request a reopening from the date on your RA.

The clerical error reopening process is not a part of the formal appeals process, but it allows providers to make a minor change to a previously filed claim, if the original claim has been denied or reduced. CMS provides the instructions for reopening activities conducted by MACs. Section 937 of the MMA required CMS to establish a process whereby providers, physicians, and suppliers could correct minor errors or omissions outside of the appeals process.

Clerical error reopenings can be done on the phone, in writing or via NGSConnex, for providers to correct minor errors, clerical errors, or omissions. The MAC reserves the right to refuse to adjust a claim as requested if it appears that such an adjustment would risk incorrect payment on any claims not identified for correction.

A provider, physician, or supplier may request a reopening up to one year from the receipt of the initial remittance notice. If the provider, physician, or supplier would like to request a reopening after the one-year time limit has expired, they may request the reopening in writing. Documentation supporting good cause to waive the timeliness requirement must be included.

CMS issued interim final regulations, which state clerical errors (which CMS likens to MMA’s minor errors or omissions), are defined as human or mechanical errors on the part of the party or the contractor, such as:

  • Mathematical or computational mistakes;
  • Transposed procedure or diagnostic codes;
  • Inaccurate data entry;
  • Misapplication of a fee schedule;
  • Computer error; or,
  • Denial of claims as duplicates which are denied as a result of a clerical error or minor omission and require a change on the face of the claim (i.e., adding or removing a modifier) in order for the claim to be reopened. (Exception: We will reopen claims that denied as a duplicate when multiple services have been billed and some are denied due to a separate claim submission; i.e., when three radiology services have been paid on one claim and a fourth one denied as a duplicate due to a separate claim submission and a request is made to allow a total of four services. A reopening can be performed even though the claim was submitted correctly and no change is being made.)
  • Incorrect data items, such as provider number, use of a modifier or date of service.

The basis of a clerical error or minor omission reopening is to correct the minor clerical or minor omission that resulted in an initial claim denial or reduction.

Types of Issues that can be performed as clerical error or minor omission reopenings:

  • Increase number of services or units (without an increase in the billed amount)
  • Add/change/delete modifiers such as 24, 25, 54, 57, 58, 59, 76, 77, 78, 79, 80, AS, or AQ (Note: Postoperative modifiers 24, 25, 57 and 58 can be added to a paid claim so the provider can submit a procedure code without having it reduced by the unrelated visit.)
  • Procedure codes
  • Place of service
  • Add or change a diagnosis on a denied service
  • Billed amounts
  • Incorrect provider number to deny
  • Incorrect HIC to deny
  • MSP unrelated – non-GHP records
  • Correcting rendering provider PTAN/NPI
  • Addition of referring provider PTAN/NPI
  • Add date last seen on the claim
  • Date of service – the date of service change must be within the same year
  • Services billed in error
  • Refunds (except 935 refunds)

Types of Issues that cannot be performed as clerical error or minor omission reopenings. For these issues providers must submit a redetermination request in writing:

  • Comprehensive Error Rate Testing (CERT)
  • Provider enrollment issues
  • Claim denial due to no response to a development request
  • Established Recovery Auditor (RA) overpayment (Telephone only)
  • Services with a high dollar amount ($7,500 or more)
  • Wrong payee
  • Complex claim situations (such as ambulance, anesthesia, Not Otherwise Classified codes, claims with modifiers 22, 23, 53, 62, 66, GA or GY or any other claim which requires analysis of documentation).
  • CMS input (e.g. services after date of death)
  • If there are multiple surgeries on multiple claims for the date of service in question

Some situations would not be appropriate for the reopening or redetermination process:

  • If the original denial is rejected as unprocessable, submit a new claim
  • If the claim in question is in process, you must wait until after the claim has processed before requesting a reopening
  • If there has been no claim submitted, submit a new claim
Level/Type Time Limit Amount in Controversy
Required (after deductible and coinsurance)
Telephone Reopening Within 1 year of receipt of the notice of initial determination. No minimum
Written Reopening Within 1 year of receipt of the notice of initial determination and within 4 years after the date of the initial determination, when the situation establishes good cause. No minimum

Telephone Reopenings

Providers may request a reopening of the original claims processing decision by contacting the Appeals Telephone Reopening Unit (TRU).

The TRU can be used when you wish to revise the initial determination or redetermination of a specific service or claim for minor clerical errors. If you have a general question or need to talk to someone about an issue that cannot be reopened, please contact our Provider Contact Center.

TRU representatives will reopen claims to correct minor, uncomplicated, provider or contractor clerical errors or omissions. However, TRU representatives cannot add items or services that were not previously billed. Please Note: Reopenings are granted at the contractor’s discretion; a claim may not be appealed if contractor decides not reopen the claim.

With the availability of the electronic remittance advice you can know the outcome prior to the complete finalization of a claim. Please ensure the claim has finalized prior to calling the TRU line to request changes to the claim.

Note: Unsolicited faxes will be returned to the sender unprocessed.

Using NGSConnex to Submit a Redetermination or Reopening Request

NGSConnex, a free and secure web-based application, has a convenient option available that providers can use to submit an appeal request for a claim redetermination or reopening online instead of submitting a paper appeal. Providers can also check the status of redeterminations/reopening requests.

For complete instructions on using NGSConnex for submitting a reopening request, visit our Reopenings for Minor Errors and Omissions section of our website.

Written Reopening Requests

Jurisdiction 6 providers in Illinois, Minnesota and Wisconsin should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Jurisdiction K providers in Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 7111
Indianapolis, IN 46207-7111

Be sure to include the following information with your reopening request:

  • The beneficiary’s name
  • The Medicare HICN of the beneficiary
  • The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
  • The name and signature of the person filing the request

Reopening requests for issues requiring documentation such as adding modifier 22 and redetermination of overpayments are not permitted. These must be submitted as a written redetermination request.
Info from: http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/job-aids-manuals/

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