Reopening

The Reopening process allows suppliers to correct clerical errors or omissions without having to request a formal appeal. Initiate a request online via the Noridian Medicare Portal (NMP), telephone, or in writing.

Access the below Reopening related information from this page.

 

Time Limit for Filing Request Time Limit 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

 

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.")

Before submitting a Reopening request, suppliers must research the claim denial reason (see Standard Paper Remittance (SPR) or Electronic Remittance Advice (ERA), call Interactive Voice Response (IVR), access NMP, or contact Supplier Contact Center) and determine the proper way to correct it.

Suppliers must wait three business days, following ERA or SPR receipt, before calling Telephone Reopenings or submitting a request via NMP.

Do not resubmit a claim after submitting a Reopening request.

Items Too Complex for a Reopening

Submit the below as a Redetermination request with supporting documentation.

  • Overutilization denials that require supporting medical records
  • Certificate of Medical Necessity (CMN) issues (applies to Telephone Reopenings only)
  • Durable Medical Equipment Information Form (DIF) issues (applies to both Written and Telephone Reopenings)
  • Oxygen break in service (BIS) issues
  • Overpayments or reductions in payment. Submit request on Overpayment Refund Form
  • Medicare Secondary Payer (MSP) issues
  • Claims denied for timely filing (older than one year from initial determination)
  • Complex Medical Reviews or Additional Documentation Requests (ADRs)
  • Change in liability
  • Recovery Auditor-related items
  • Certain modifier changes or additions: EY, GA, GY, GZ, K0 - K4, KX, RA (cannot be added), RB, RP
  • Certain HCPCS codes: E0194, E1028, K0108, K0462, L4210, All HCPCS in Transcutaneous Electrical Nerve Stimulator (TENS) LCD, All National Drug Codes (NDCs), miscellaneous codes and codes that require manual pricing

Note: The above is not an all-inclusive list.

Telephone Reopening

To complete a Telephone Reopening, a caller must provide the below.

Verified by Customer Service Representative (CSR) or IVR Verified by CSR
  • 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 Reopening

General Requests

Suppliers may submit a Written Reopening request via mail, fax, or as a Self-Service Reopening in NMP.

Mail or Fax Self Service Reopening via NMP
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 requires correction
    • Copy of RA
    • Supporting documentation which includes CMN(s), etc.

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

Request details must be completed in NMP. Log In Now. One request per beneficiary.

View Self-Service Reopening webpage for details

 

Special Project Requests

To submit a Written Reopening special project request, the claim(s) affected must be finalized. (i.e. SPR or ERA has been generated)

To avoid a possible dismissal, follow the instructions below.

  1. Submit a Written Reopening request by mail, fax, or via NMP
    • Mail or fax: Complete Medicare DME Reopening Request Form. See Written Reopening Requests mailing address or Appeals - Reopening and Redeterminations fax number. One request form per beneficiary. If supplier has a list of beneficiary claims, may attach spreadsheet(s)
      • Inlclude below in Comments section of form
        • "Special Project Request - See attached spreadsheet"
        • Total number of pages including coversheet
        • Spreadsheet(s)
    • NMP Self-Service Reopening: Request details must be completed within NMP. Supplier may attach spreadsheet(s) when there is a list of beneficiary claims
      • NMP is limited to submission of 70 megabyte files so check file size of spreadsheets before submission
  2. Attach a Spreadsheet, if applicable
    • Access Reopening Spreadsheet Template
    • JA and JD claims cannot be on same spreadsheet, even if for same PTAN. Suppliers must submit separate requests for JA and JD
    • Spreadsheet must be typed with font large enough to be easily read. Hand written documents are not accepted
    • Do not add any coloring to spreadsheet. This is not accepted
    • Spreadsheet must include:
      • Supplier NPI and PTAN
      • Beneficiary Full Name
      • Beneficiary Medicare Number
      • DOS
      • HCPCS Codes
      • CCN - list each claim number only once on spreadsheet

Reopening Decision Correspondence

Decision Type of Correspondence
Fully Favorable
  • Telephone: New RA is issued
  • Written: New RA is issued
Partially Favorable
  • Telephone: Supplier is notified on call why services are not allowed and new RA is issued
  • Written: Letter is mailed and new RA is issued
Unfavorable
  • Telephone: Supplier is notified on call why services are not allowed
  • Written: Letter is mailed to supplier detailing why services are not allowed

 

Last Updated Aug 14, 2018