Reopening - JD DME

Effective June 1, 2020, suppliers are required 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. All claim denials are not available for reopening, some need to be corrected and rebilled, while others require a formal appeal.

Once a denial is received, suppliers should determine what action to take to resolve that denial and reopening is one of those actions. The Denial Code Resolution page will help guide suppliers on what action to take.

• Available for reopening
• Initiate a Reopening Request
  • Self-Service Reopening Required in NMP
  • Telephone Reopening Required
  • Written Reopening Required
  • Spreadsheets/Special Projects
• Items Too Complex for a Reopening (claim must be appealed)
• Prior to Submitting Reopening Request
• Action Resolving Denial
  • Rebill
  • Reopening
  • Redetermination/Appeal
• Reopening Time Limit
• Reopening Decision Correspondence

Available for Reopening

Minor clerical errors or omissions 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.

Initiate a Reopening Request

Methods to submit a reopening.

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

Note: This is not an all-inclusive list

Self-Service Submission Method

• Log in to the NMP - One request per beneficiary
• View NMP Inquiry Guide webpage for details

Telephone Reopening Required

Must be completed on phone - claim not available as self-service reopening on portal

• Only three Reopenings at a time over phone
• 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

Note: This is not an all-inclusive list

Elements Required for Telephone Reopening

• 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 Required

• Some wheelchair accessories
• Some narratives
• Most IVIG
• KU modifier
• KY modifier

Note: This is not an all-inclusive list

Written Reopening Methods

• Through appeals function on the NMP
  • Log in to the NMP - One request per beneficiary
  • View NMP Inquiry Guide webpage for details
• 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

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

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

• 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
  • Adding or Removing - CR
  • Adding or Removing - CG
• 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

Prior to Submitting Reopening Request

Before submitting a Reopening request, suppliers should research the claim denial reason and remark codes to determine if a reopening is the proper action to take in resolving the denial and avoid it in the future. This can be accomplished through:

• Noridian Medicare Portal (NMP)
• Standard Paper Remittance (SPR)
• Electronic Remittance Advice (ERA)
• Interactive Voice Response (IVR)

Action Resolving Denial

When a denial is identified, including the reason and remark codes, 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?

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

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 or is denial for medical necessity or other qualifying denial?

Note: 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.

Reopening Time Limit

Reopening Decision Correspondence