Fact Sheet: Which Form Should I Use?

Form WPS Medicare Redetermination Request Form WPS Medicare Reopening Request Form
What Do I Use This Form For? To request an appeal when dissatisfied with the outcome of the initial claim determination or overpayment decision To request a correction for minor billing errors or omissions
When Do I Use This Form? Use the Redetermination Request Form when the following occur (including, but not limited to):
  • Claim changes that create an overpayment situation
  • You disagree with an overpayment request (demand letter sent)
  • Claim denial resulting from CERT (Comprehensive Error Rate Testing)
  • Claim denials resulting from Provider Enrollment issues (not valid or eligible provider number)
  • Claim was submitted with the wrong Payee
  • Adding services that were not previously billed (i.e. increase number of services with an increase in the billed amount)
  • Add/Change/Delete modifiers such as 22, 62, or 66
  • Complex claim situations that require analysis of medical documentation to make payment, i.e. ambulance claims, billing for not otherwise classified (NOC) codes, billing for more frequent services due to patient's medical condition, etc.
  • Claim denials due to services provided after the date of death or prior to CMS and SSA eligibility information has been updated.
 Use the Reopening Request Form:
  • To correct clerical errors (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
    • Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate
  • Some examples of clerical errors are:
    • Increasing the number of services or units (without an increase in the billed amount)
    • Adding/Changing/Deleting modifiers such as 24, 25, 58, 76, 78, 79, or GA
    • Fixing transposed procedure codes
    • Changing place of service or date of service that affect a denied service
    • Changing or adding diagnosis code on a denied service.
    • Note: we cannot reopen a claim to change a diagnosis code or add a modifier if the change does not change the outcome of the initial determination decision.


Note: If the initial determination payment cannot be changed, we cannot process the request as a redetermination or reopening.

Page Last Updated: Friday, 03-Feb-2012 12:37:37 CST