To request a reopening, you must report a new type of bill (TOB), XXQ, along with condition codes to indicate that the claim is a request for reopening. All providers must use this TOB XXQ reopening process when a correction is to be made beyond the timely filing limit (one year from the through date of the service).
Full Answer
How do I re-open a Medicare Part a claim?
Complete a Medicare Part A redetermination/clerical error reopening request form only for those situations where you are unable to do the DDE adjustment. An accepted request for a claim reopening will result in a new remittance advice notification, which will list the new DCN for the adjusted claim.
How do I file a D9 reopening request for Medicare?
When D9 is used, an explanation must be included in the REMARKS filed (FISS Page 4). Enter ' W2 ' (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process.
How do I adjust a claim for a reopening request?
For reopening requests entered via Direct Data Entry (DDE), from the Fiscal Intermediary Standard System (FISS) Main Menu, select Claims Correction (Option 03), then, select the Claim Adjustments options 33 (home health) or 35 (hospice).
Can I submit a reopening to add items not previously billed?
You cannot submit a reopening to add items or services not previously billed. A clerical error reopening is defined per the CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 34 - Reopening and Revision of Claim Determinations and Decisions, section 10.6:
What is a Medicare clerical reopening?
A clerical error/omission reopening is an action taken to change an initial determination to correct minor errors or omissions outside of the Medicare appeal process.
What is a Medicare reopening request?
A reopening is a remedial action taken to change a binding determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are separate and distinct from the appeals process.
What is a reopening in CMS?
The Reopening process allows providers to correct clerical errors or omissions without having to request a formal appeal. Most reopenings can be initiated through Self Service Reopenings via the Noridian Medicare Portal (NMP). All other requests can be initiated by telephone or in writing.
What is Bill type XXQ?
To request a reopening, you will report a new Type of Bill (TOB), XXQ, along with condition codes to indicate that the claim is a Request for Reopening.
How do I reopen a noridian claim?
0:203:33Noridian Medicare Portal: Self Service Reopenings for Part B UsersYouTubeStart of suggested clipEnd of suggested clipFirst once you have found the claim you're wanting to reopen. Choose view claim to initiate theMoreFirst once you have found the claim you're wanting to reopen. Choose view claim to initiate the reopening choose self-service reopening under the related inquiry. Section.
What is Medicare disallowance?
A disallowed amount is simply the difference between what has been billed by the health care provider and what the insurance company has paid. These amounts are not billed to the patient; instead, they are written off by the health care provider.
How do I bill a corrected Medicare claim?
To submit a corrected claim to Medicare, make the correction and resubmit it as a regular claim (Claim Type is Default) and Medicare will process it.
How do I submit a claim to noridian Medicare?
ContactContact.855-609-9960.
Does noridian accept corrected claims?
A claim should only be resubmitted if the claim rejects for missing, invalid, or incomplete information. When a claim processes, a provider should follow the reopening or appeal process to make corrections to the claim. Q19. My patient has a Medicare Advantage Plan and Medicare.
What does NUBC stand for?
National Uniform Billing CommitteeThe National Uniform Billing Committee (NUBC) was formed in 1975 to develop and maintain a single billing form and standard data set to be used nationwide by institutional, private and public providers and payers for handling health care claims.
What is Medicare's timely filing for Part B?
12 monthsPolicy: The time limit for filing all Medicare fee-for-service claims (Part A and Part B claims) is 12 months, or 1 calendar year from the date services were furnished.
What is the DME reopening number?
The DME MAC telephone reopening number is 1-866-813-7878. This line is in service Monday through Friday, from 7 AM to 5 PM, Central Standard Time. Note: The easiest, fastest, and most efficient way to complete a Telephone Reopening request is via the myCGS Web Portal. Use the telephone reopening process to resolve minor errors or omissions ...
Can you appeal a Medicare claim?
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. In the case where a minor error or omission is involved, 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.
Request a Reopening
Note: Unprocessable claims with Remittance Advice (RA) message MA130 cannot be reopened. ("Your claim contains incomplete and/or invalid information, and no appeal or Reopening rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.")
Items Too Complex for a Reopening
Submit the below as a Redetermination request with supporting documentation.
Written Reopening
Suppliers may submit a Written Reopening request via mail, fax, or as a Self-Service Reopening in NMP.
What is a reopening request?
When a claim correction is discovered and the claim is beyond the timely filing limit (one calendar year from the "through" date on the claim), a reopening request (TOB XXQ) can be submitted. If a claim needs correcting and the claim is within the timely filing limit, an adjustment (TOB XX7) can be submitted.
How long does retroactive Medicare entitlement last?
Retroactive Medicare entitlement involving State Medicaid Agencies. State Medicaid Agency recoups payment six months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished, the beneficiary was only entitled to Medicaid and not to Medicare.
Can a claim be reopened with a medical review?
Note: Claim lines denied through Medical Review are not allowed to be reopened; however, claim lines not denied through Medical Review can be reopened. Also, claims with a status of RTP cannot be reopened with the TOB XXQ. For RTP claims, you must submit a new claim and provide remarks on the claim as to why you are billing the claim past ...
Is the claim override timeliness process expired?
The customer service telephone claim override timeliness process has expired. Part A providers are required to follow the coding and billing guidelines outlined in SE1426, which adheres to the exceptions established by CMS to request an extension of time limit provision.
Can a provider submit a claim to Medicare?
The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare , because the timely filing limit has expired (See 70.7.3). Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization.
What is a redetermination in Medicare?
A redetermination is a written request, for a first level appeal, to the Medicare administrative contractor to review claim data when you are dissatisfied with the original claim determination. The redetermination is an independent process to re-evaluate the claim.
What happens if you request a redetermination?
If the request for a redetermination is not approved or unfavorable, you will receive a letter notifying you of the decision. Requesting a redetermination.
Can you file a redetermination over the phone?
Requests for redeterminations may not be filed over the telephone. All written redeterminations must contain the following items: The beneficiary name. The beneficiary Medicare number. The specific service (s) and/or item (s) for which the redetermination is being requested. The specific date (s) of service.
Reopening Instructions
In accordance with the instructions contained in 42 Code of Federal Regulations (CFR) 405.1885 and the Provider Reimbursement Manual ( PRM) 15-1, chapter 29, sections 2931 through 2932 , a cost report may be reopened if a written request to reopen is received within three years from the date that the Notice of Amount of Program Reimbursement (NPR) was issued.
Clarification of What Constitutes the Same Issue for Reopenings
42 CFR 405.1885 indicates that an audited cost report can be reopened within three years of the original NPR date. Once a cost report is reopened, a provider then has three years from the date of the revised NPR to request a reopening if the request is for the same issue as the original reopening.
What is a clerical error reopening?
A clerical error reopening is a process that allows you to change claim data without submitting a written appeal. You can fax a clerical error reopening form. You cannot submit a reopening to add items or services not previously billed.
What is a redetermination in Medicare?
A redetermination is a written request, for a first level appeal, to the Medicare administrative contractor to review claim data when you are dissatisfied with the original claim determination. The redetermination is an independent process to re-evaluate the claim.
How long does it take to file a redetermination?
At this point, if applicable, you can file a new redetermination if it's within the 120-day timeframe. If a redetermination is not accepted and sent to general inquires it must meet privacy requirements or it may not process. The privacy requirements include:
Can a claim be appealed?
Claims that are considered to be unprocessable (missing, incomplete, or invalid information which is needed to process the claim) cannot be appealed, thus causing the redetermination to be returned to you with a letter of unacceptance.
Claim Correction Reopening
- When the need for a claim correction is discovered and the claim is beyond the timely filing limit (1 calendar year from the "through" date on the claim), a reopening request (type of bill (TOB) XXQ) must be submitted to remedy the error. When a claim needs correction and the claim is within the timely filing limit, an adjustment (type of bill XX7) may be submitted. Reopenings are t…
Untimely Filing
- Claims are rejected for untimely filing when the claim is submitted 12 months after the date the services were furnished. The Centers for Medicare & Medicaid have established exceptions to the one calendar year time limit. For additional information, refer to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70.7. At this time, a hardcopy UB-04 adjustment, or a reopenin…
56900 Reopenings
- Claims are denied with reason code 56900 when the claim was selected for an additional development request (ADR), but the medical documentation was not received by CGS, or was not received timely. A "56900 reopening" may be requested to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals ...
Ordering/Referring Denial Reopenings
- Claims are denied with reason code 32072, 37236, 37237, or 37247 when the NPI and/or physician's last name or first name submitted on the home health claim does not match the physician's information at the Provider Enrollment, Chain, and Ownership System (PECOS). While claims denied for this reason will appear in status/location D B9997, the claim should be appeal…
Overview
- If you made a minor error or omission in filing a claim, you can likely submit a reopening request to correct the error rather than file an appeal/redetermination. The easiest, fastest and most efficient way to correct or reopen a claim is to utilize the myCGS web portal. You can use the claim correction or claim reopening features, which are both under the Reprocessing tab. You ca…
myCGS Reopenings
- The fastest and easiest way to submit a reopening request is through the DME myCGS web portal. 1. If you are not using the myCGS portal, get started by following steps in the Registration Guide. 2. If you are registered for the myCGS portal, refer to the “Reopenings” section of “Chapter 6 – Reprocessing” in the myCGS User Guidefor detailed submission instructions.
Telephone Reopenings
- The DME MAC telephone reopening number is 866.813.7878. This line is in service Monday through Friday, 7 am – 5 pm CT. Use the telephone reopening process to resolve minor errors or omissions involving: 1. Units of service 2. Service dates 3. Healthcare Common Procedure Code System (HCPCS) coding 4. Modifiers (excluding the KX, GA, GY and/or GZ mod...
Written Reopenings
- Written reopenings can be mailed or faxed. Suppliers should use the Medicare Reopening Request Form for submissions, and refer to the Medicare Reopening Request Form Complete Guidefor helpful information. If you wish to send a written request instead of using the Medicare Reopening Request Form, be sure to include the following information with your reopening request: 1. The b…
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