Reopening

The Reopening process allows suppliers to correct clerical errors or omissions without having to request a formal appeal. A reopening request can be initiated 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 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

Prior to calling Telephone Reopenings, research 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 proper way to correct claim. Telephone Representatives cannot determine claim actions

Wait three (3) business days, following receipt of ERA, to call Reopenings or submit a Written Reopening to ensure claim in question has finalized

Do not resubmit a claim after requesting a Reopening

If upon research during a telephone reopening, any of the changes are determined too complex, the caller will be notified the request must 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:
    • KH, KI, KJ, RR, NU, AU, KL, RT, LT

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

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
  • Medicare Secondary Payer (MSP) issues
  • Claims denied for timely filing
  • Reopenings past one year from initial determination
  • Complex Medical Reviews or Additional Documentation Requests (ADRs)
  • Advance Beneficiary Notice of Noncoverage (ABN) issues and other liability issues
  • 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.

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

Telephone Reopening

A caller must provide the below elements when requesting a Telephone Reopening. A request cannot be completed without it.

Information will be verified by representative or the IVR

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

Information will be verified by representative

  • Supplier name
  • Beneficiary Medicare number
  • Beneficiary first and last name
  • DOS
  • HCPCS code(s) in question
  • Corrective action to be taken

Additional details that may need to be verified

  • DOS
  • Provider/Facility Name
  • Last five digits of Claim Control Number (CCN)
  • Procedure code in question

Note: A Reopening cannot be requested for claims that contain remark code MA130. Such claims are considered unprocessable and do not have Reopening or Appeal rights. The claim is missing information that is required for processing or was invalid and must be resubmitted.

Written Reopening

General Written Reopening Requests

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

Mail or Fax Self Service Reopening via NMP
Complete and submit Medicare DME Reopening Request Form
  • The items below must be included on the form
    • Clear statement that explains error or omission
    • Beneficiary name
    • Beneficiary Medicare number
    • Name and address of supplier of item/service
    • Specific date(s) of service(s)
    • Item and/or services which needs correction
    • Copy of Medicare Remittance Advice (RA)
    • Supporting documentation which includes Certificates of Medical Necessity (CMN), etc.

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

Request details must be completed within NMP. One request per beneficiary.

View Self-Service Reopening webpage for details

 

Written Reopening Special Project Requests

For a Written Reopening special project request to be submitted, the claim(s) affected must be finalized, i.e. supplier has received a SPR or ERA for the claim.

To initiate a request, a supplier must call Phone Reopenings to notify us that a special project spreadsheet is being submitted with a request. See Supplier Contact Center webpage for phone number

  • Reopening Customer Service Representative will provide an authentication number for request - This must be done for each NPI and PTAN combination for which there are adjustments
  • Requestor must also receive different authentication numbers for JA and JD - Authorization numbers can only be used once

When the authentication number(s) are obtained, the request process can begin. To avoid a possible dismissal, follow the instructions below.

  1. Submit a Written Reopening request by mail, fax or via the Noridian Medicare Portal (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). Access spreadsheet template and view requirements below
      • In Comments section of form, the below must be included:
        • "Special Project Request – See attached spreadsheet"
        • Authentication number
        • Total number of pages including coversheet
        • Spreadsheet(s)
    • NMPSelf-Service Reopening: Request details must be completed within NMP. If supplier has a list of beneficiary claims, may attach spreadsheet(s). Access spreadsheet template and view requirements below. NOTE: NMP is limited to submission of 70 megabyte files so check the file size of large 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. Hand written documents are not accepted
    • Do not add any coloring to spreadsheet. This is not accepted
    • Spreadsheet font must be large enough to be easily read and must include below information
      • Supplier NPI and PTAN
      • Authentication Number
      • Beneficiary Full Name
      • Beneficiary Medicare Number
      • Date(s) of Service
      • HCPCS Codes
      • CCN - list each claim number only once on spreadsheet

Reopening Review Notification

Decision Type of Correspondence
Favorable A new Remittance Advice (RA) and payment will be issued
Partially Favorable

A new RA and partial payment will be issued

Telephone: Supplier is notified on call why additional services were not allowed
Wirtten: Supplier will receive letter explaining adjustment and why additional services were not allowed

Unfavorable

Telephone: Supplier is notified on call why services were not allowed
Wirtten: Supplier will receive letter explaining why services were not allowed

 

Email Reopening Inquiries

Suppliers may email, dmeredeterminations@noridian.com, questions and concerns regarding the below Reopening related topics.

NOTE: Confidential information cannot be emailed. This includes Protected Health Information (PHI), such as patient names, claim information, Beneficiary Medicare numbers, Social Security Numbers (SSNs), CCNs, or Supplier numbers. This type of information cannot be emailed because it may be possible for others to view the contents.

  • 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
     

Last Updated Jan 12, 2018