Medical Review Reopening

The Medical Review (MR) process allows providers to request an MR claim reopening when the denial is identified as related to missing and/or insufficient documentation. This process allows MR the discretion to perform an additional review of new or different documentation; it is not a re-review of initially submitted documentation.

Providers may contact their clinical reviewer to discuss if an MR reopening may be completed. The clinical reviewer is listed in the file notification letter he/she received.

To ensure a submitted provider request meets the requirements, MR will evaluate it. If MR determines the claim can be reopened, a Reopening form will be sent to the provider within three business days of the initial discussion with the clinical reviewer.

  • Provider must fax Reopening form and additional sufficient documentation (medical records) within required time frame (See form for fax number and time frame)
  • Failure to submit form/documentation by deadline will revoke MR reopening rights
    • If revoked, provider may submit a redetermination request if he/she still desires review of the additional documentation

NOTE: MR will not consider reopening a claim when there is no new additional documentation to review. If a provider would like a review of the same documentation, a redetermination request may be submitted. See the Redetermination webpage for instructions on how to submit appeals for an original determination.
 

Last Updated Aug 13, 2018