Reopening and Redetermination Tips - JD DME

A DME MAC Program Manager Update

In previous articles, we shared how the Noridian and CGS Program Managers oversee a variety of operational and collaborative workgroups that meet monthly to discuss opportunities for DME MAC process improvements across all four DME MAC jurisdictions.

In this article, the Program Managers want to share the most common reopening and redetermination tips.

Please keep the following tips in mind before you submit your reopenings and redeterminations so that we can process your request in an efficient and comprehensive manner.

Reopening Tips

• Self-service reopenings required to be completed through the DME MAC portal (not an all-inclusive list)
  • Billed amount
  • Billed in error
  • Date of service
  • Diagnosis
  • Modifier (exceptions KX, GA, GY, GZ)
  • MSP type
  • Place of service (exceptions 31 & 32)
  • HCPCS code
  • Correct Referring/Rendering provider - PECOS updated reprocessing only
    • All PECOS issues must be directed to the PECOS contractor before reaching out to the DME MAC.
  • Reprocessing
  • Units
• Reopenings must be filed within one year of the date of claims determination.
• Telephone reopening
  • 90-day supplies
  • Place of service 31 and 32
  • Narrative for accessories/supplies for beneficiary-owned items - Requires HCPCS and purchase month/year of base item
  • Prescriber NPI/name changes
    • Updates to NPI and name changes to PECOS must be directed to the PECOS contractor.
  • Adding dispensing fee - Requires paid drug and CCN of billed dispensing fee
  • Date of death now on file
    • Claims prior to date of death
  • Medicare is now primary
• Elements required for telephone reopenings
  • National Provider Identifier (NPI)
  • Provider Transaction Access Number (PTAN)
  • Last five digits of Tax Identification Number (TIN)
  • Caller's name
  • Provider/facility name
  • Beneficiary Medicare number
  • Beneficiary first and last name
  • Date of service (DOS)
  • Last five digits of Claim Control Number (CCN)
  • HCPCS code(s) in question
  • Corrective action to be taken
  • Written reopenings can be completed through the DME MAC portal, mail, or fax. Mail or fax must include a reopening request form available on the DME MAC websites. Written reopenings can be completed for any item; however, the following items must be completed through a written reopening."
    • Some wheelchair accessories
    • Some narratives
    • Most IVIG
    • KU modifier
    • KY modifier

Redetermination Submission Tips

• Unprocessable claims contain message MA130 ("Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.") Correct any errors and submit as a new claim.
• Duplicate redetermination requests cannot be processed. Be sure to research to ensure that a redetermination request was not already submitted.
• Include proper and legible documentation such as medical records, prescriptions, refill requests, proof of delivery, and/or the Advance Beneficiary Notice of Noncoverage (ABN) as appropriate. Do not include a corrected claim.
• If medical notes are not legible, the appeal will remain denied as the medical documentation received cannot be reviewed.