Reopenings vs. Redeterminations Job Aid
Contents
1. e Procedures denied for exceeding Medically Unlikely Edits Note Documentation supporting medically reasonable and necessary units of service should be included with the request e Claims adjusted causing an overpayment may be appealed with supporting documentation The above list is not an all inclusive list of when to submit an appeal RESOURCES 1 Internet Only Manual Publication 100 04 Chapter 34 Reopening and Revision of Claim Determinations and Decisions https Awww cms gov manuals downloads clm104c34 pdf 2 Internet Only Manual Publication Publication 100 04 Chapter 29 Appeals of Claim Decisions https www cms gov manuals downloads clm104c29 pdf Revised November 16 20152. and other natural catastrophes FIVE LEVELS OF APPEALS First level of Appeals is a Redetermination All Redeterminations are handled by qualified CGS employees that were not involved in the initial claim determination Providers suppliers must submit a Redetermination within 120 days of the initial claim determination A minimum monetary threshold is not required to request a Redetermination Second Level of Appeals is a Reconsideration After the Redetermination process is completed a provider supplier has an option to submit a Reconsideration All Reconsiderations are handled by a Qualified Independent Contractor QIC The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals Providers suppliers must submit a Redetermination within 180 days of receipt of the Redetermination decision A minimum monetary threshold is not required to request a Reconsideration Third Level of Appeals is an Administrative Law Judge Hearing After completing the Reconsideration process a provider supplier has the option of requesting a Administrative Law Judge ALJ Hearing A request for an ALJ hearing must be made within 60 days of receipt of the Reconsideration decision Effective January 1 2016 at lest 150 must remain in controversy following the QICs decision Fourth Level of Appeals is an Appeals Council Review If a provider supplier is dis
3. and QW e Adding additional line items that were not already billed e Requests to recoup money e Patient s Name HIC number changes e Change provider name PTAN or NPI for referring ordering or performing physician information e Add notes in block 19 on the CMS 1500 claim form Revised November 16 2015 e Errors in Medicare processing claims reduced in error keyed incorrectly scanned incorrectly duplicate in error e Upcoding to New Patient Visits which also includes the Welcome to Medicare Visit HCPCS code G0402 and the Annual Wellness Visit Codes HCPCS codes G0438 and G0439 e Requests from providers who are currently receiving payment adjustments reductions as a result of the Electronic Prescribing eRx Electronic Health Record EHR and or Physician Quality Reporting System PQRS Incentive Programs When to Use Written Reopenings e Adding or changing modifiers e g CPT modifiers 24 25 57 58 78 79 59 7 7 76 50 e Changes in the date of service within the same year different years have to be handled by Overpayment Recovery e Procedure code s billed in error and paid if the new code will allow the same or more money e Submitted amount e Number of units e Diagnosis submitted e Reduced services e Adding CPT modifiers 22 53 54 55 and HCPCS modifiers KX and QW e Timely Filing Denials e Reopening requests from providers who are currently receiving payment adjustments reductions as a re
4. 00 p m EST CGS Part B Reopening Telephone number 1 866 276 9558 option 4 Please keep in mind that the telephone reopening representatives assist as many callers as possible each day When calling please indicate that you are requesting a telephone reopening The following information is needed for verification All items must match exactly e The Billing provider s physician s supplier s name e Both the Provider Transaction Access Number PTAN and NPI e Last 5 digits of the TIN Revised November 16 2015 e Beneficiary s complete name and e Medicare HIC number The following items shall be obtained recorded confirmed during the telephone reopening e Date of call e Name of caller e Phone number of the party e Date s of service e Item s or service s in question e Rationale for not processing the request if applicable e Name of reviewer and e Confirmation number if claim is adjusted Written Reopenings A written reopening is a hard copy request of clerical errors or omissions to be corrected on a Medicare claim For your convenience CGS has created the Medicare Part B Reopening Adjustment Request Form http www cgsmedicare com forms reopening form pdf The form should be mailed to Attention Written Adjustments CGS PO Box 20018 Nashville TN 37202 It is important that the form be completed in its entirety and be legible We suggust completing the form online then printing to incl
5. PDF format and no more than 5MBs in size Providers can also track the status of the Reopening request To submit a request for Reopening through myCGS step by step instructions are available in the Part B provider section of Chapter 7 http www cgsmedicare com pdf myCGS chapter7_partb pdf in the myCGS User Manual NOTE Allowing Reopening requests to be submitted through myCGS is being offered as a convenience myCGS Reopenings are processed under the same guidelines as hardcopy requests In addition the timeframe to process a Reopening sent via myCGS is no different than a hardcopy request When submitting Reopenings please note the following e Inquiries will not be processed as Reopenings Reach out to the Provider Contact Center with inquiries http www cgsmedicare com partb cs index html e Do not submit duplicate requests e Check for accuracy PRIOR TO submitting the form to avoid errors e If erroneous Reopenings are submitted do not resubmit corrections until the initial request is finalized e Reopenings may take up to 60 days to process Do not send second and third requests Telephone Reopenings A provider can request a telephone reopening of clerical errors or omissions that can be corrected quickly and easily over the telephone CGS ensures that the Privacy Act of 1974 5 USC 552a is applied to its telephone reopening process The Telephone Reopening line is available from 8 00 a m 5
6. Reopening vs Redetermination Job Aid Table of Contents Reopenings Types of Reopenings Redeterminations When to Use a Redetermination Resources d S Revised November 16 2015 A CELERIAN GROUP COMPANY 2015 Copyright CGS Administrators LLC CENTERS FOR MEDICARE amp MEDICAID SERVICES REOPENINGS A Reopening is a process used to correct minor errors or omissions to a previously processed claim without using the formal appeals process CMS defines clerical errors including minor errors or omissions as human or mechanical errors on the part of the party or the contractor such as e Mathematical or computational mistakes e Transposed procedure or diagnostic codes e Inaccurate data entry e Misapplication of a fee schedule e Computer errors or e Incorrect data items use of a modifier or date of service A reopening must be requested within one year from the date of the initial determination The law provides that Reopenings may be done to correct minor errors or omissions that are clerical errors The contractor has discretion in determining what meets this definition and therefore what could be corrected through a reopening NOTE Reopening requests received with invalid or inaccurate information cannot be processed and will be returned with a system generated letter Inquiries will not be accepted if sent as a Reopening Examples of inquiries include e Asking for the status of claims o
7. mentation REDETERMINATIONS The Redetermination is the first level of appeals Medicare regulation states that a party who is dissatisfied with an initial determination may request a contractor review of such determination Your redetermination request must include the reason you are requesting a review and must include documentation that supports your reason for requesting the redetermination myCGS Redeterminations Redetermination requests are accepted through the myCGS web portal by completing the online Redetermination request form Providers who are registered users may complete and submit the form There is also an Appeals Time Limit Calculator to help ensure the request is timely The following information must be included on a Medicare Part B myCGS Redetermination Beneficiary Information e Patient s Name e Patient s State e Medicare HIC number e Patient s Phone Number Along with the completed Redetermination form providers must attach at least one document to the request no more than five Attachments must be in a PDF format and up to 5MBs in size Submission ID numbers are assigned to each case which can be used to track the status of the Redetermination request To submit a request for Redetermination through myCGS step by step instructions are available in the Part B provider section of Chapter 7 http www cgsmedicare com pdf myCGS chapter _partb pdf in the myCGS User Manual You may also submi
8. onvenience CGS allows providers to submit their Medicare Part B Reopenings Adjustment Request form via fax Please ensure that you use the fax number applicable for your state e Kentucky 1 615 664 5914 e Ohio 1 615 664 5924 NOTE Illegible requests will be returned with a system generated letter When submitting hardcopy requests we suggest completing the form online then printing to obtain signatures The timeframe to process a Reopening may take up to 60 days Do not send second and third requests When To Use Telephone Reopenings The requests handled by the Telephone Reopening include not an all inclusive listing e Adding or changing modifiers e g CPT modifiers 24 25 57 58 78 79 59 76 50 e Changes in the date of service within the same year different years have to be handled by Overpayment Recovery e Procedure code s billed in error and paid if the new code will allow the same or more money e Submitted amount e Number of units e Diagnosis submitted The following requests cannot be handled by Telephone Reopening not an all inclusive listing e Unprocessable Denials Remark Code MA 130 Claims without appeal rights e Medicare Secondary Payer Claims e Reduced services e Place of Service e Claims that are more than a year old from the original remit date e Unlisted procedure codes e Claims that have demand requests for refund e Add CPT modifiers 22 53 54 and HCPCS modifiers KX
9. r Reopening requests previously submitted e Questions regarding denied and or rejected Return to Provider RTP claims e Questions on the amount paid on processed claims e Requests to reprocess previously submitted claims without identifying specific error or changes needed Inquiries must be handled by the Provider Contact Center For options please go to http cgsmedicare com partb cs index html TYPES OF REOPENINGS myCGS Reopenings Providers who register to use myCGS our secure online web portal may submit Reopening requests electronically to correct minor errors or omissions to claims previously processed Requests may be submitted for a single beneficiary multiple beneficiaries and for a single beneficiary with Medicare Secondary Payer MSP involved The following information must be included on a Medicare Part B myCGS Reopening Provider Information e Provider s Address e Provider s Phone Number 2015 Copyright CGS Administrators LLC Page 2 e Last 5 digits of Tax Identification Number TIN e National Provider Identifier NPI Beneficiary Information e Name e Patient s Address e Medicare Health Insurance Claim HIC number e Patient s Phone Number There are no limits to the number of Reopening requests you may submit Simply complete the online form in its entirety and attach supporting documentation if applicable Up to 5 attachments may be included All attachments must in a
10. satisfied with the ALJ s decision an Appeal Council Review can be requested The request for Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ s decision and must specify the issues and findings that are being contested There are no requirements regarding the amount of money in controversy 2015 Copyright CGS Administrators LLC Page 5 Fifth Level of Appeals is a Judicial Review in U S District Court The final level of appeals consists of a judicial review before a US District Court judge The appellant must file the request for review within 60 days of receipt of the Appeals Council s decision For requests filed on or after January 1 2016 1 500 or more must still be in controversy following the Appeals Council s decision For additional information please visit http www cms gov MLNProducts downloads MedicareAppealsProcess pdf WHEN TO USE A REDETERMINATION e Ambulance denials Note Run tickets should be included to support each trip e Charges denied as Part A because the patient was seen in the office prior to admission in the hospital Note Documentation should be included to support the office service e Shared care denied for global service already on file Note Documentation of the share care should be included to support the service billed e Claim denied as not medically necessary and the provider has supporting documentation to support the medical necessity
11. sult of the Electronic Prescribing eRx Electronic Health Record EHR and or Physician Quality Reporting System PQRS Incentive Programs e Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate Exceptions If the denial is for medical necessity a redetermination with supporting documentation must be sent to the contractor Acceptable Duplicate Denial Example A provider received a duplicate denial for billing multiple chest x rays for the same patient on same date of service with all appropriate modifiers The provider should submit a Written Reopening Adjustment request form identifying the claim denied in error as a duplicate A Redetermination is not needed in the above scenario because additional documentation is not needed The change of information may result in an overpayment Additional supporting documentation may be required with the written reopening request The following requests cannot be handled by Written Reopenings not an all inclusive listing e Unprocessable Denials Remark Code MA 130 Claims without appeal rights e Claims that have demand requests for refund e Adding additional line items that were not already billed e Requests to recoup money e Patient s Name HIC number changes 2015 Copyright CGS Administrators LLC Page 4 e Medical Unlikely Edit MUE denials exceeding the MUE limit Note Must file a Redetermination with supporting docu
12. t your request on the Medicare Part B Jurisdiction 15 Redetermination Form http www cgsmedicare com pdf PartB_ RedeterminationForm pdf This form is not required but we recommend you use this form to help ensure that you have included all required information The Redetermination request must be sent to CGS Attention Redeterminations PO Box 20018 Nashville TN 37202 NOTE CGS does not accept Redetermination requests via fax Redetermination requests must be submitted within 120 days from the initial claim determination If a request is received after 120 days and a good cause can be found for late filing please indicate the Revised November 16 2015 good cause reason on line 6 of the Redeterminations Request form Good cause may be found when the record clearly shows or the provider physician or other supplier alleges and the record does not negate that the delay in filing was due to one of the following e Incorrect or incomplete information about the subject claim and or appeal was furnished by official sources CMS the contractor or the Social Security Administration to the provider physician or other supplier or e Unavoidable circumstances that prevented the provider physician or other supplier from timely filing a request for redetermination Unavoidable circumstances encompasses situations that are beyond the provider physician or supplier s control such as major floods fires tornados
13. ude the signature Failure to do so may cause the request to be returned with a system generated letter identifying the request could not be honored at this time Providers may attach supporting documentation However if a CMS 1500 claim form is submitted with the Written Reopening Request Form the requestor must give specific details of what corrections to make and include the corrected CMS 1500 claim form that matches the requested information For example the Written Reopening Request Form may indicate to correct the submitted amount add a specific modifier or correct a diagnosis code to a procedure code However the new submitted amount modifier or diagnosis code is not listed on the attached CMS 1500 corrected claim form This will prompt a letter to be sent back to the provider asking to specify the correction needed The following items must be included on the Medicare Part B Reopening form e State in which the service was rendered e Date of completion of the form e Provider Information Name Last 5 digits of TIN PTAN Provider s Address NPI Provider s Phone Number e Beneficiary Information Name Patient s Address Medicare HIC Number Patient s Phone Number 2015 Copyright CGS Administrators LLC Page 3 e Service Date e HCPCS CPT e Internal Control Number ICN of the claim e Reason for the Request e Supporting Documentation e Completed By Signature For your c
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