Reopening

Effective June 1, 2020, Noridian began requiring suppliers to use the Noridian Medicare Portal (NMP) for all reopenings that are available through the Self-Service Reopening feature.

The Reopening process allows suppliers to correct clerical errors or omissions on denials received without having to request a formal appeal. Suppliers can initiate a request:

  • Self-Service reopening online via the Noridian Medicare Portal (NMP)
  • Telephone
  • Written
  • Spreadsheets/Special Projects
    • Call the Phone Reopenings to get the directions
      • If a spreadsheet is sent in without the correct information, it will be dismissed and a letter sent to the supplier

Minor clerical errors or omissions available for reopening include:

  • Diagnosis/procedure changes
  • Place of service changes - to POS 12 only
  • Date of service changes
    • The date of service cannot be changed to a date greater than the date that claim was originally received
    • Must be within the same calendar year except for Glucose and Nutrition
  • Modifier changes
  • Units of service changes
  • Billed Amount changes - Submitted amount and change amount must be < $10,000 (or must be sent to appeals)

Note: This is not an all-inclusive list.

Prior to Submitting Reopening Request

Before submitting a Reopening request, suppliers should research the claim denial reason to determine the proper way to resolve the denial and avoid it in the future. This can be accomplished through:

When the denial is identified, utilize the Denial Code Resolution Tool for guidance in resolving the denial. There are three options for resolving the denial. Correct the claim and rebill, reopening, and redetermination/appeal.

  • Rebill - Is the claim unprocessable which means the claim needs to be corrected and rebilled?
  • Reopening - Does the claim meet requirements for reopening?
    • Does not require documentation review
    • Not previously reopened or appealed
    • Not under review by Noridian or other review contractors
    • Not unprocessable indicated by denial code MA130
      • Resubmit/rebill these claims with corrections
    • HCPCS or denial reason not listed under too complex for reopening
    • Claim was not already paid
    • The remittance advice date must be within one year of the current date
    • The claim must be finalized
  • Redetermination/Appeal - Does the claim contain items too complex for a reopening and requires redetermination/appeal?

Suppliers must wait three business days following ERA or SPR receipt before submitting a request via the NMP or calling Telephone Reopenings. Do not resubmit a claim after submitting a Reopening request.

Unprocessable Claims - Correct and Rebill

Claims with remittance advice (RA) message MA130 cannot be reopened as they are unprocessable. "Your claim contains incomplete and/or invalid information, and no appeal or Reopening rights are afforded because the claim is unprocessable." Correct and submit a new claim with the complete/correct information.

Requesting a Reopening

There are three methods to submit a reopening.

Review below for more information on all three submission methods.

Noridian Medicare Portal (NMP) Self-Service Submission

See listing below for types of Reopenings that must be completed in the NMP.

Note: This is not an all-inclusive list.

Self-Service Reopening Required in NMP

  • Billed amount
  • Billed in error
  • Date of service
  • Diagnosis
  • Modifier
  • MSP type
  • Place of service (exceptions 31 & 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
  • Units and billed amount
  • Units, modifiers (some exceptions), and billed amounts

Telephone Reopening Submission

  • May be completed on phone - claim not available as self-service reopening on portal
    • Only three Reopenings at a time over phone
  • Caller must provide certain information
    • 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

See listing below for types of reopening that must be completed through a telephone reopening.

Note: This is not an all-inclusive list

Telephone Reopening

  • 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
  • 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 narratives

Written Reopening Submissions

  • Noridian Medicare Portal (NMP) through appeals function
  • Mail or Fax
    • Complete/submit Medicare DME Reopening Request Form
    • Must be included on form:
      • Clear statement that explains error or omission
      • Beneficiary name
      • Beneficiary Medicare number
      • Name and address of supplier of item/service
      • Specific DOS
      • Item and/or services which require correction
  • Items to include with written reopenings include:
    • Written request form
    • CMNs
    • Medicare EOB
    • 1500 form

Please do not include documents not required.

See the Written Reopening Requests mailing address and Appeals - Reopening and Redeterminations fax number.

See listing below for types of reopening that must be completed through a written reopening.

Note: This is not an all-inclusive list

Written Reopening Required

  • Some wheelchair accessories
  • Some narratives
  • Most IVIG
  • CR modifier - requires narrative
  • KU modifier
  • KY modifier
Time Limit for Filing Request Time Limit for DME MAC to Complete Request Filing Options
One year from initial determination date or after one year from receipt date due to overpayment via clerical error omissions 60 days from receipt date

 

Items Too Complex for a Reopening (claim must be appealed)

Submit claim denials for the reasons below as a Redetermination request with supporting documentation. This can be accomplished through the Noridian Medicare Portal (NMP), mail or fax.

Note: This is not an all-inclusive list.

Too Complex for Reopening - Submit to Redetermination With all Documentation Requirements

  • Overutilization denials - requires supporting medical records
  • Oxygen break in service (BIS) issues
  • Medicare Secondary Payer (MSP) issues (except Medicare 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 manually priced items - NOC codes and claims requiring specific narratives
  • Certain modifier changes
    • Adding or removing liability modifiers - EY, GA, GY, GZ, GX, KX
    • Specialty modifiers - JW, K0 - K4, KE, KK, RB, RP
    • Adding or Removing - RA
    • Adding or Removing - KG, KT
  • Certain HCPCS codes:
    • Common codes - E0194, E1028, K0108, K0462, L4210
    • K1018 - K1019
    • All HCPCS in TENS LCD
    • All National Drug Codes (NDCs)
    • All miscellaneous codes and codes that require manual pricing
  • Noncovered items/services per LCD
  • Claims with previous recoupment or refund requests
  • Claims with equipment in a non-covered status

Reopening Decision Correspondence

Decision Type of Correspondence
Fully Favorable New remittance advice (RA) is issued
Partially Favorable Telephone: supplier is notified by phone the reason services are not allowed, and a new RA is issued

Written: letter is mailed, and a new RA is issued
Unfavorable Telephone: supplier is notified by phone the reason services are not allowed

Written: letter is mailed to supplier detailing why services are not allowed

 

Last Updated Mon, 09 Jan 2023 19:49:31 +0000