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Reopenings

Medicare Claims Processing Manual (Pub. 100-04, Ch. 34External PDF).

CGS performs four types of reopenings:

Review the information below to determine the correct type of reopening to request, and the appropriate process to follow when submitting the request.

Claim Correction Reopening

When the need for a claim correction is discovered and the claim is beyond the timely filing limit (1 calendar year from the "through" date on the claim), a reopening request (type of bill (TOB) XXQ) must be submitted to remedy the error. When a claim needs correction and the claim is within the timely filing limit, an adjustment (type of bill XX7) may be submitted.

Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of CGS. Minor errors or omissions may include:

  • Transposed procedure/diagnostic codes
  • Incorrect provider number or date of service
  • Inaccurate data entry
  • Mathematical or computational mistakes

Note: Omissions do not include failure to bill items/services, such as late charges. A reopening may be requested to change a claim determination that resulted in an overpayment or underpayment, even though the decision was correct when the claim was processed.
Reopenings are separate from the appeals process, and therefore, do not count towards the five levels of appeal.

Note: Reopenings (TOB XXQ) cannot be submitted with a hardcopy (paper) UB-04. They must be submitted via the 5010 format or entered directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE).

For reopening requests entered via Direct Data Entry (DDE), from the Fiscal Intermediary Standard System (FISS) Main Menu, select Claims Correction (Option 03), then, select the Claim Adjustments options 33 (home health) or 35 (hospice). In addition to the usual field locators and the information being adjusted, reopenings (TOB XXQ) must include the following information. If there is a medically denied line item on the claim, FISS may not allow you to complete the adjustment electronically. If you are unable to submit the reopening electronically or via DDE, you may submit a hard copy adjustment using the Clerical Error Reopening Request FormPDF.

Field Name/Requirement

Description

TOB
(FISS Page 1)

32Q – home health reopening
34Q – home health outpatient reopening
81Q – hospice (nonhospital based) reopening
82Q – hospice (hospital based) reopening

Once the claim being reopened is selected, you must change the third digit of the TOB field to 'Q' to identify the adjustment claim as a reopening request.

COND CODES
(FISS Page 1)

Enter the appropriate condition code.

R1 – Mathematical or computational mistake
R2 – Inaccurate data entry
R3 – Misapplication of a fee schedule
R4 – Computer errors
R5 – Incorrectly identified duplicate
R6 – Other clerical error or minor error or omission (failure to bill a service is not considered a minor error).
R7 – Correction other than clerical error
R8 – new and material evidence is available
R9 – Faulty evidence (initial determination was based on faulty evidence)

COND CODES
(FISS Page 1)

Enter a condition code that best describes what is being changed.

D0 – Changes in service date
D1 – Change to charges
D2 – Changes in revenue code/HCPCS/HIPPS Rate Codes
D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes
D9 – Change in condition codes, occurrence codes, occurrence span codes, provider ID, modifiers and other changes
E0 – Change in patient status

When D9 is used, an explanation must be included in the REMARKS filed (FISS Page 4). 

COND CODES
(FISS Page 1)

Enter 'W2' (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process. A reopening request cannot be submitted if an appeal has been requested, and a decision is pending or in process.

ADJUSTMENT REASON CODE
(FISS page 3)

FISS will automatically assign one of the codes below.
R1 – Less than 1 year from the initial determination (Remittance Advice (RA) date)
R2* – 1 – 4 years from the initial determination (RA date)
R3* – Greater than 4 years from the initial determination (RA date)

*Requires "Good Cause" to be documented by submitting a "Remark".

REMARKS
(FISS page 4)

Remarks are always helpful in processing a reopening; however, the REMARKS field is required when the R2 or R3 Adjustment Reason Code is submitted. Remarks should be formatted for a change or addition (C-A), new and material evidence (NME) and faulty evidence (F-E) with a narrative explanation. NOTE: The first 15 characters of the remark must match exactly as shown below.

  • Good_Cause-_C-A (underline indicates a space)
  • Good_Cause-_NME (underline indicates a space)
  • Good_Cause-_F-E (underline indicates a space)

Example: Good Cause- C-A to add revenue code 0550 because…

If the change or addition affects a line item, please indicate which line(s) is/are being changed.

Resources

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Untimely Filing

Claims are rejected for untimely filing when the claim is submitted 12 months after the date the services were furnished. The Centers for Medicare & Medicaid have established exceptions to the one calendar year time limit. For additional information, refer to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70.7External PDF. At this time, a hardcopy UB-04 adjustment, or a reopening request may be submitted if one of the exceptions apply.

Reason for Untimely Filing

Submitting Hardcopy Adjustment

Submitting a Reopening – Can only be submitted via 5010 or FISS Direct Data Entry (DDE)

Claim rejected (R B9997 or P B9997) with reason code 39011 due to timely filing edits.

  1. Medicare HHH Reopening Adjustment Request FormPDF
  2. Adjustment claim (XX7) on a hardcopy UB-04 claim form, with the necessary adjustment coding (condition code, DCN, and remarks)
  3. Documentation to support an exception to override timely filing.

NOTE: To determine the correct DCN to report on your adjustment, select the denied claim (TOB 329). Go to Page 02 and press F2. The DCN of the claim will appear in the upper left corner in the "DCN" field.

Requests for untimely filing reopenings, along with supporting documentation, must be mailed to:

J15 – HHH Claims
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202

Detailed coding information can be found under the "Claim Correction Reporting" heading of this Web page.

  1. TOB with the third digit of "Q", (XXQ)
  2. Condition Codes (R7, R8, or R9)
  3. Condition Code D9 (Other Changes)
  4. Condition Code W2
  5. Adjustment Reason Code (R1, R2, or R3)
  6. Remarks (required when adjustment reason code R2, R3, or condition code D9 are submitted). Refer to the "Remarks" section (above) under the "Claim Correction Reopening" heading.

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56900 Reopenings

Claims are denied with reason code 56900 when the claim was selected for an additional development request (ADR), but the medical documentation was not received by CGS, or was not received timely. A "56900 reopening" may be requested to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process.

Reason for 56900 Reopening

Required Documentation

Claims denied for 56900 (no/untimely response to ADR)

"CGS Medicare HHH Jurisdiction 15 Redetermination Request FormPDF" to CGS. Providers should note "56900 Reopening Request" in the "Reasons/Rationale" field.

Requests for 56900 reopenings, along with medical documentation, must be mailed to:

J15 – HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202

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Ordering/Referring Denial Reopenings

Claims are denied with reason code 32072, 37236 or 37237 when the NPI and/or physician's last name or first name submitted on the home health claim does not match the physician's information at the Provider Enrollment, Chain, and Ownership System (PECOS). While claims denied for this reason will appear in status/location D B9997, the claim should be appealed using the Reopening process, rather than the redetermination process.

Reason for Ordering/Referring Reopening

Required Documentation

Claim denied for ordering/Referring physician NPI and/or name

  1. Medicare HHH Reopening Adjustment Request FormPDF
  2. Adjustment claim (XX7) on a hardcopy UB-04 claim form, with the appropriate NPI and physician name, and necessary adjustment coding:
    • Condition code
    • Document Control number (DCN) – NOTE: To determine the correct DCN to report on your adjustment, select the denied claim (TOB 329). Go to Page 02 and press F2. The DCN of the claim will appear in the upper left corner in the "DCN" field.
    • Remarks

Refer to the Adjustments/Claims Web page for additional information.

Requests for ordering/referring denial reopenings, along with a hardcopy UB-04, must be mailed to:

J15 – HHH Claims
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202

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Updated: 09.17.20

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