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Reopening

Overview

The Reopening process allows suppliers to correct clerical errors or omissions without having to request a formal appeal. A reopening can be initiated via the telephone, in writing or online through the Noridian Medicare Portal.

A contractor (Noridian) reserves the right to refuse to adjust a claim as requested if it appears that such an adjustment would risk incorrect payment on any claims not identified for correction.

Time Limit for Filing Request Monetary Threshold to be Met Time Limit to Complete Request Where to File Filing Options
One year from initial determination date or after one year from receipt date due to overpayment via clerical error omissions None 60 days from receipt date Contractor

 

Request a Reopening for the Following

This list is not all-inclusive. If upon research during a telephone reopening, any of the changes are determined too complex, the caller will be notified the request will need to be sent in writing as a redetermination with the appropriate supporting documentation.

  • Diagnosis code changes or additions
  • Date of service (DOS) changes
  • HCPCS code changes
  • Certain modifier changes or additions (not an all-inclusive list)
    • KH
    • KI
    • KJ
    • RR
    • NU
    • AU
    • KL
    • RT
    • LT

Items Too Complex for Reopenings

The below must be submitted as a Redetermination request with supporting documentation.

  • Overutilization denials that require supporting medical records
  • Certificate of Medical Necessity (CMN) issues
  • 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
  • Medicare Secondary Payer (MSP) issues
  • Claims denied for timely filing
  • Reopenings past one year from the initial determination
  • Complex Medical Reviews or Additional Documentation Requests
  • Advance Beneficiary Notice of Non-coverage (ABN) issues and other liability issues
  • Miscellaneous HCPCS codes and all HCPCS codes that require manual pricing
  • Recovery Auditor-related items
  • The following modifier changes or additions:
    • EY
    • GA
    • GY
    • GZ
    • K0 through K4
    • KX
    • RA (cannot be added)
    • RB
    • RP
  • Certain HCPCS codes (not all-inclusive list):
    • B4159-B4162
    • E0194
    • E1028
    • K0108
    • K0462
    • L4210
    • All HCPCS in the Transcutaneous Electrical Nerve Stimulator (TENS) Policy
    • All National Drug Codes (NDCs)

Telephone Reopening Requirements

Listed below is the information that is required when calling to request a Reopening. If you do not have this information, a Reopening request will not be able to be completed.

This information will be verified by either a representative or the IVR:

  • National Provider Identifier (NPI)
  • Provider Transaction Access Number (PTAN)
  • Last five digits of Tax Identification Number (TIN)

This information will be verified by a representative:

  • Supplier name
  • Beneficiary's Health Insurance Claim Number (HICN)
  • Beneficiary's first and last name
  • DOS
  • HCPCS code(s) in question
  • Corrective action to be taken

Additional details that may need to be verified

  • Date of service
  • Provider/Facility Name
  • Billed amount
  • Procedure code in question
  • Beneficiary's date of birth

Note: Claims with remark code MA130 can never be submitted as a reopening (telephone or written). Claims with remark code MA130 are considered unprocessable and do not have reopening or appeal rights. The claim is missing information that is needed for processing or was invalid and must be resubmitted.

Helpful Hints

  • Be sure to research the claim denial reason (see Remittance Advice, call IVR or Supplier Contact Center) and the proper way to correct the claim prior to calling Reopenings. Telephone Representatives cannot determine claim actions.
  • Wait three business days, following receipt of the electronic remittance advice (ERA), to call Reopenings to ensure that the claim in question is finalized.
  • Notify a Telephone Reopenings representative if more than 50 of the same correction will be requested. The representative will gather the required information and provide further direction how to submit the request.
  • Do not resubmit a claim after completing a telephone reopening.
  • If calling to check on the status of a claim, call the Interactive Voice Response (IVR).

Written Reopening Requirements

To submit a reopening request by mail or fax:

Or

  • Write a letter to Noridian. The letter must include all of the following information:
    • Clear statement that explains the error or omission;
    • Beneficiary name;
    • Beneficiary Medicare number;
    • Name and address of the supplier of the item/service;
    • Specific date(s) of the service(s);
      • Be specific when indicated dates of service. Do not request 01/01/15 - present, for example. This should be listed as 02/01/15, 03/01/15, 04/01/15.
    • Which item and/or services needing correction;
    • Copy of the Medicare remittance advice; and
    • Supporting documentation including Certificates of Medical Necessity (CMNs), DME Information Forms (DIFs), etc.

Filing Limits

Physicians, suppliers, Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations may request a reopening.

  • Reopening requests must be received within one year from the date the claim completed processing as determined by the date paid on the beneficiary's Medicare Summary Notice (MSN) or the supplier's Electronic Remittance Advice (ERA) or the Standard Paper Remittance (SPR).
  • Reopening requests received after the one year time limit will be dismissed as an untimely request.
  • The contractor may, upon request by the party affected, extend the period for filing the request for reopening.
  • Good cause for late filing will not be considered over the phone and is not applicable for telephone reopenings.

Reopening requests are mandated by CMS to be completed by the contractor within 60 days from the date the request is received within our office.

Notification

If a reopening is approved, a Standard Paper Remittance (SPR) or Electronic Remittance Advice (ERA) will notify the supplier of the payment determination. A separate determination letter for fully favorable reopenings will not be sent.

Email Reopenings Inquiries

Questions and concerns regarding reopenings may be emailed to dmeredeterminations@noridian.com:

  • Timely Filing Inquiries
  • Appeal Regulations
  • Coverage Questions
  • Appeal Rights
  • Documentation Requirements for Redeterminations
  • Redetermination/Reopening Request Forms
  • Redetermination Letter Wording
  • Social Security Laws
  • Interpretation of Denial Messages
  • Policies

Confidential information cannot be e-mailed. This includes Protected Health Information (PHI), such as patient names, claim information, Health Insurance Claim (HIC) numbers, Social Security numbers, Claim Control numbers (CCNs) or supplier numbers. This type of information cannot be e-mailed because it may be possible for others to view the contents.

This e-mail option is for suppliers only and is not to be used by beneficiaries.

Last Updated May 22, 2017

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