Reopenings
Medicare Claims Processing Manual (Pub. 100-04, Ch. 34).
CGS performs four types of reopenings:
- Claim Correction Reopening (beyond the claims timely filing limit);
- Untimely Filing (rejected claims (R B9997) with reason code 39011)
- 56900 Reopenings (denials due to no medical review additional development request (ADR) documentation received by CGS); and
- Ordering/Referring Denial Reopenings (home health only).
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:
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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 Form.
Field Name/Requirement |
Description |
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TOB |
32Q – home health 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 |
Enter the appropriate condition code. R1 – Mathematical or computational mistake |
COND CODES |
Enter a condition code that best describes what is being changed. D0 – Changes in service date When D9 is used, an explanation must be included in the REMARKS filed (FISS Page 4). |
COND CODES |
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 will automatically assign one of the codes below. *Requires "Good Cause" to be documented by submitting a "Remark". |
REMARKS |
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.
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
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, §70.7. 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) |
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Claim rejected (R B9997 or P B9997) with reason code 39011 due to timely filing edits. |
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 |
Detailed coding information can be found under the "Claim Correction Reporting" heading of this Web page.
If additional information is requested by CGS, the reopening adjustment will be RTP'd with a note on the Remarks page. Please note, no letter will be sent by CGS. |
56900 Reopenings
Claims deny with reason code 56900 when a medical review contractor doesn’t receive your documentation in response to an additional documentation request (ADR) letter within the required timeframe (45 calendar days for CGS). Review the Medical Review Additional Documentation Request Process: Prepayment Review and Postpayment Review pages to learn how to avoid these claim denials.
A 56900 reopening request allows the Medical Review department to complete a review without using the Medicare Appeals process.
When to Submit |
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How to Submit |
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What to Submit |
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Ordering/Referring Denial Reopenings
Claims are denied with reason code 32072, 37236, 37237, or 37247 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.
Avoid Ordering/Referring Denials
To avoid ordering/referring denials, refer to the Ordering/Referring Physician Checklist for Home Health Agencies quick resource tool and follow the three easy steps.
Reason for Ordering/Referring Reopening |
Required Documentation |
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Claim denied for ordering/Referring physician NPI and/or name |
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
Updated: 10.20.23