How to Request a Reopening

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. The Centers for Medicare & Medicaid Services (CMS) provide the instructions for reopening activities conducted by carriers. Section 937 of the Medicare Modernization Act (MMA) required CMS to establish a process whereby providers, physicians, and suppliers could correct minor error or omissions outside of the appeals process.

Clerical Error Reopenings can be done on the phone or in writing, and for provider minor errors, clerical errors, or omissions. The Carrier 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 that 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 (if the change will allow additional payment):

  • 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, 78, 79, 80, AS, AQ or GA (Note: Post operative 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 (If payment is affected)
  • Add or change a diagnosis on a denied service
  • Billed amounts
  • Provider numbers (except when an overpayment is involved)
  • Date of service. The date of service change must be within the same year.

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:

  • CERT (Comprehensive Error Rate Testing)
  • Provider Enrollment issues
  • Claim denial due to no response to a development request
  • Established RAC overpayment (Telephone only)
  • Services with a high dollar amount ($7,500 or more)
  • Wrong payee
  • Adding services that were not previously billed (i.e. increase number of services with an increase in the billed amount)
  • Complex claim situations (such as ambulance, anesthesia, Not Otherwise Classified codes, claims with modifiers 22, 55, 62, 66, or GY or any other claim which requires analysis of documentation).
  • CMS input (e.g. services after date of death)
  • If there is a pending or finalized redetermination or a higher level appeal request
  • 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 co- insurance)
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

Page Last Updated: Thursday, 05-Apr-2012 12:32:55 CDT