Skip to Main Content

Print | Bookmark | Email | Font Size: + | –

February 26, 2015

Reminder: Reopening Process for Claims Denied for Ordering/Referring Edits

CGS has recently received some inappropriate appeal requests for claims which were denied due to the ordering/referring physician edits. As a reminder, claims will deny with reason code 37236 or 37237 when the attending or certifying physician's National Provider Identifier (NPI) or name submitted on the claim does not match the name/NPI on the Provider Enrollment, Chain and Ownership System (PECOS) file, or the physician is not an eligible type to order/refer.

When a claim is denied with 37236 or 37237, the only recourse to receive Medicare payment is to request a Reopening. Do not resubmit a new claim or submit a redetermination request.

Follow theses steps to request a Reopening for the 37236 or 37237 denial reason codes.

  1. Access the "Medicare HHH Reopening Adjustment Request FormPDF"
  2. Complete the form with the following required information:
    1. Check the 'Home Health' box
    2. Enter the date of the request in the 'Date' field
    3. Complete all information under the 'Provider Information' and 'Beneficiary Information' sections
      1. Enter the dates of service of the claim in the 'Service Date' field
      2. Enter the denied Document Control Number (DCN) of the denied claim in the 'Document Control Number (DCN)' field
    4. Under the Reason for Request section, check the box indicating "Ordering/Referring Physician Denials"
    5. Under the 'Supporting Documentation' section, check the 'UB-04 Form' box.
    6. The person completing the Reopening form must print their name in the 'Contact Name' field, enter a phone number in the 'Contact Phone Number' field, and sign in the 'Signature' field on the form.
  3. Submit a hardcopy (paper) UB-04 adjustment claim (type of bill 327) with the Reopening form. The UB-04 must include the usual home health claim information. In addition, ensure the following information is included:
    1. The correct ordering/referring physician's NPI and name
    2. Condition code 'D9' (FL 18-28)
    3. The DCN (FL64) of the denied claim
    4. Remarks (FL80) indicating the reason for the adjustment (i.e., correcting physician NPI and name)
  4. Mail the Reopening form, and the UB-04 hardcopy claim to the J15-HHH Claim address listed on the bottom of the form.
    1. Note: If the ordering/referring physician's PECOS record has not yet been updated, do not submit your reopening request. The physician must work with their Part B Medicare Administrative Contractor (MAC) to add/update their PECOS record.

For additional information about the reopening process, please refer to the "Reopenings" Web page on the CGS website.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved