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What is a reopening? A reopening is an action taken by a fiscal intermediary, carrier, Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) or a Part A/B MAC to change a final determination or decision on a Medicare fee-for-service claim that resulted in either an overpayment or an underpayment. What is the difference between a reopening and an appeal? The first and most significant difference between a reopening and an appeal is that granting a physician's, provider's, supplier's, or beneficiary's request for a reopening is at the discretion of the contractor, it is not mandatory. However, the right to appeal is mandatory, provided the appeal request is valid and the requestor is an appropriate party. For more information on who may appeal a Medicare claim denial and what constitutes a valid request for appeal please refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 29, sections 210—Who May Appeal and 310.1 (B)—What Constitutes a Request for Redetermination. Beneficiaries can get more information by calling 1-800-MEDICARE or referring to their Medicare and You Handbook. Procedurally, both the reopening and the appeal are the re-review of an initial determination, including medical records and any submitted documentation. In this case, the term "initial determination" is referring to the first judgment Medicare made about payment or denial of payment on a claim for an item or service. When should I request a reopening and when should I request an appeal? If there is an error on your claim that constitutes a minor or clerical error, you should request a reopening. However, if you disagree with a Medicare policy or decision regarding the medical necessity of the item or service in question, you should request an appeal. What can I do if a contractor does not accept my request for a reopening? When a claim is first denied, you have 120 days to request a redetermination, which is the first level of the Medicare claim appeals process. If the contractor does not accept your request for reopening and this 120 days has not expired, then you may request a redetermination. However, if the 120 days has expired, then there is no further action available to you. Since reopenings are discretionary, a contractor's decision to not grant a request for reopening is not subject to appeal. As a provider, I usually submit an adjusted or corrected claim to my fiscal intermediary to correct errors, can I still do that? Yes. This process is still available to providers. You should work with your fiscal intermediary to determine what can be corrected through an adjusted or corrected claim. If a contractor agrees to reopen my claim, when will I know the outcome of the reopening and is there any limit on the amount of time the contractor can take to make its decision? If you request a reopening and a contractor agrees to reopen your claim, the contractor must make its decision on that reopening within 60 days. Please note that if your request involves 40 or more claims and/or 40 or more beneficiaries, and $40,000 or more in controversy, the 60 day time limit does not apply. There are also telephone reopenings that are conducted by Part B contractors. You may find out the outcome of your telephone reopening while you are still on the phone. If the request requires further review, the contractor will inform you (the caller) that they will either follow-up with a telephone call, a letter, or a revised remittance advice informing you of the outcome of their decision. Should I file a request for a reopening and a request for an appeal, just to be safe? No. If you are unsure that the issue on your claim is a minor or clerical error, then you should file a request for an appeal. If you file both a request for an appeal and a request for reopening, the contractor will need to consider your request for a reopening as null and void. What happens if a contractor grants my reopening request, but then denies my claim for a different reason (e.g., the claim originally denied because of a clerical error, once the error was corrected, the claim denied because it was not medically necessary)? If a contractor grants a request for a reopening and denies your claim for a different reason, they will notify you of their decision and the rationale for their decision. That revised determination is new and therefore you would have 120 days from the date of that revised determination to request an appeal. For further information, scroll down to "Related Links Inside of CMS" and then go to MLNProducts-CR 4147 QAs or contact your provider call center (if the call center number is unknown, scroll down to "Related Links Inside of CMS' and then go to the MLN Matters General Info page and then click on "Provider Call Center Toll Free Numbers Directory"):
Page Last Modified: 10/16/2008 3:50:39 PM
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