Reopening Claims: Understanding Your Options

Have you ever faced a claim denial and wondered about your next steps? Can you reopen the claim without an appeal, or is it necessary to correct and rebill it? Look no further, as the Noridian Medicare webpage provides comprehensive answers and guidance on this matter. Understanding the avenues for reopening claims is crucial, and we are here to help.

Here is a breakdown of the types of claims reopenings:

Self-Service Reopening Through Noridian Medicare Portal (NMP):

  • Billed amount
  • Billed in error
  • Date of service
  • Diagnosis
  • Modifier
  • Medicare Secondary Payer (MSP) type
  • Place of service (exceptions 31 and 32)
  • Procedure code and billed amount (some exceptions)
  • Procedure code, modifier (some exceptions), and billed amount
  • Referring provider - PECOS updated reprocessing only
  • Rendering provider - PECOS updated reprocessing only
  • Reprocessing a claim
  • Units and billed amount
  • Units, modifiers (some exceptions), and billed amounts

Telephone Reopening Required:

  • 90-day supplies
  • Place of service 31 and 32
  • Duplicate denials (situational)
  • Narrative for accessories/supplies for beneficiary-owned items (requires HCPCS and purchase month/year of base item)
  • Referring or Ordering Physician PECOS changes (requires NPI and name per PECOS enrollment)
  • Adding dispensing fee (requires paid drug and CCN of billed dispensing fee)
  • Date of death now on file
  • Medicare now primary
  • Adding some CR (Catastrophe/disaster related) narratives

Written Reopening Required:

  • Some wheelchair accessories
  • Some narrative additions
  • Most Intravenous Immune Globulin Demonstration (IVIG) claims
  • KU (DMEPOS item subject to DMEPOS Competitive Bidding Program Number 3) modifier addition
  • KY (DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 5) modifier addition

Too Complex for Reopening and Must Be Appealed (with supporting documentation):

  • Overutilization denials (requires supporting medical records)
  • Oxygen break in service (BIS) issues
  • Medicare Secondary Payer (MSP) issues (except when Medicare is now primary)
  • Medical reviews or additional documentation requests (ADRs)
  • Change in liability - beneficiary responsibility denial request
  • Timely filing (older than one year from initial determination)
  • Recovery Auditor (RAC) related items
  • Transcutaneous Electrical Nerve Stimulators (TENS) policy
  • Duplicate denials (situational)
  • Miscellaneous and - NOC codes and claims requiring specific narratives
  • Manually priced items
  • Adding or removing modifiers:
    • Liability modifiers - EY, GA, GY, GZ, GX, KX
    • Specialty modifiers - JW, K0, K1, K2, K3, K4, KE, KK, RB, RP
    • RA
    • KG, KT
    • CR
    • CG
  • Certain HCPCS codes:
    • Common codes - E0194 (air fluidized bed), E1028 (wheelchair accessory), K0108 (wheelchair component or accessory, K0462 (loaner equipment during repair), L4210 (repair of orthotic device)
    • K1018 - K1019 (external upper limb tremor stimulator and supplies and accessories)
    • All National Drug Codes (NDCs)
  • Noncovered items/services per LCD
  • Claims with previous recoupment or refund requests
  • Claims with equipment in a non-covered status

Remember that most reopenings can be managed efficiently through the self-service Noridian Medicare Portal, with exceptions outlined above. For clarity on which reopening method to use, the Noridian Medicare webpage offers detailed guidance. Understanding these procedures can streamline the claims reopening process and ensure effective resolution. And just a reminder, for any claim that has already been appealed, the reopening process is not available.

 

Last Updated Oct 19 , 2023