Reopenings are conducted at the discretion of the Medicare Administrative Contractor (MAC), and are used to correct claims with clerical errors, which include minor errors and omissions. However, providers typically submit claim adjustments in these situations, as they are able to adjust fully paid or rejected claims (status/location (S/LOC) P B9997 or R B9997 in the Fiscal Intermediary Standard System (FISS)) that have posted information to the Common Working File (CWF).
CGS may grant a reopening when a valid, timely appeal request (redetermination) is received for a home health or hospice claim that was fully denied (S/LOC D B9997 in FISS) because the requested Additional Development Request (ADR) documentation was not received within the time frame specified. Denials for this reason are assigned a reason code 56900. Home health and hospice providers may continue to submit a completed redetermination form (CMS-20027) to CGS to request a reopening for 56900 denials.
In addition, reopenings may also be granted in the situation where there was a contractor error when reviewing the medical documentation for a home health or hospice claim, which resulted in an inappropriate full or partial denial (S/LOC D B9997 or P B9997 in FISS).
Reopenings are conducted outside of the Medicare Fee-For-Service appeals process.
To request a reopening for reasons other than a 56900 denial, providers should submit a letter to CGS that contains:
- the beneficiary’s Health Insurance Claim Number (HICN);
- the dates of service that were denied;
- a sentence requesting a reopening; and
- the contractor error that occurred which caused the full or partial denial.
When appropriate, mail the reopening to:
J15 — HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202
For additional information on reopenings, see the Medicare Claims Processing Manual (Pub. 100-04, Ch. 34).