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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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Reopenings for Minor Errors and Omissions

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Overview

If you made a minor error or omission in filing a claim, you can likely submit a reopening request to correct the error rather than file an appeal/redetermination.

The easiest, fastest, and most efficient way to correct or reopen a claim is to utilize the myCGS web portal. You can use the claim correction or claim reopening features, which are both under the Reprocessing tab.

You can also request a reopening for minor errors or omissions either by telephone or in writing. You have one year to request a reopening from the date on your Remittance Advice (RA). Use the Reopenings ChartPDF to see which submission methods you can use for different types of claim adjustments.

Examples of minor errors or omissions include:

  • Mathematical or computational mistakes
  • Transposed procedure or diagnostic codes
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Incorrect data items, such as the use of a modifier or date of service
  • Claims denied for being filed after the claim filing time limit

The following are examples of what cannot be handled as a Reopening:

  • Not reasonable and necessary (not medically necessary) claim denials MUST be appealed through redeterminations
  • Claims denied by another review contractor – Unified Program Integrity Contractor (UPIC), Supplemental Medical Review Contractor (SMRC), Medical Review (MR), Recovery Audit Contractor (RAC), and Comprehensive Error Rate Testing (CERT) – MUST be appealed through redeterminations
  • Requests to extend the date for the end of the 13-month rental period due to a break in service/break in need, or to start a new capped rental period, can be appealed through redeterminations, or you can submit a new claim with the appropriate narrative information for the break in service or break in need
  • Unprocessable/Returned claims (such as ANSI code 16) – resubmit the claim with the corrected information
  • Addition, change, and/or removal of KX, GA, GY, and/or GZ modifiers – MUST be appealed through redeterminations
  • Recoupment requests which should be submitted to overpayment recovery
  • Corrected PTANs

Because some issues are more complicated than others and may require more research or consulting medical staff, the DME MAC reserves the right to decline the clerical error reopening and request that you submit a written redetermination.

Click below to learn more details about different submission types.

myCGS Reopenings

The fastest and easiest way to submit a reopening request is through the DME myCGS web portal.

  • If you are not using the myCGS portal, get started by following steps in the Registration Guide.
  • If you are registered for the myCGS portal, refer to the "Reopenings" section of "Chapter 6 – Reprocessing" in the myCGS User Guide for detailed submission instructions.

Telephone Reopenings

The DME MAC telephone reopening number is 866.813.7878. This line is in service Monday through Friday, 7 am – 5 pm CT.

Use the telephone reopening process to resolve minor errors or omissions involving:

  • Units of service
  • Service dates
  • Healthcare Common Procedure Code System (HCPCS) coding
  • Modifiers (excluding the KX, GA, GY and/or GZ modifier)
  • Place of service

Wait to call the telephone reopening line until you receive your Medicare remittance notice. No action can be taken until a final claim determination is issued.

Callers should consult the Jurisdiction C DME MAC Supplier Manual and applicable medical policy guidelines before calling. Failure to have appropriate information available when you call the telephone reopening line may result in an unfavorable decision.

The telephone reopening line is not a resource for questions about the status of a claim, general Medicare payment, or coding. Suppliers can obtain a claim status report by using the myCGS web portal or find information on the Interactive Voice Response (IVR) system or Claim Status Inquiry (CSI).

Suppliers must have the following information on-hand before placing the call for a telephone reopening:

  • Your PTAN, NPI and last five digits of TIN
  • The Medicare Claim Control Number (s) (CCN) and reason for denial
  • Date(s) of Service
  • Medicare Beneficiary Identifier (MBI)
  • Any additional information to support why you believe the decision is not correct. This includes having the correct procedure code(s), modifier(s), units of service, etc.

All medical information provided to the DME MAC must be documented in the patient's file and available to the DME MAC, should an audit be required.

If a previous reopening decision has been issued, suppliers must submit a written redetermination.

To effectively service all callers, each call is limited to five claim issues. Calls involving multiple PTANs are limited to 3 claim issues.

The following issues are examples of what cannot be handled on the telephone reopening line:

  • Claims denied for being filed after the claim filing time limit
  • Unprocessable/Returned claims (such as ANSI code 16) – resubmit the claim with the corrected information
  • Medicare Secondary Payer (MSP)/other insurance involvement issues – A secondary payer is an insurance plan that covers medical expenses only after a primary insurer has made payment on a claim
  • Any claim that requires additional documentation
  • Addition, change, and/or removal of KX, GA, GY, and/or GZ modifiers
  • Inquiries related to denial of payment based on entitlement
  • Questions that are general in nature and not claim specific
  • Requests to extend the date for the end of the 13-month rental period due to a break in service/break in need, or to start a new capped rental period, can be appealed through redeterminations, or you can submit a new claim with the appropriate narrative information for the break in service or break in need
  • CMN or DIF issues or changes
  • Claims denied by another review contractor – Unified Program Integrity Contractor (UPIC), Supplemental Medical Review Contractor (SMRC), Medical Review (MR), Recovery Audit Contractor (RAC), and Comprehensive Error Rate Testing (CERT) – MUST be appealed through redeterminations
  • Not reasonable and necessary (not medically necessary) claim denials MUST be appealed through redeterminations

Disclaimer: If any of the above changes, upon research, are determined to be too complex, the phone representative will inform the caller that these need to be sent in writing with the appropriate documentation as a written reopening or as a redetermination.

Written Reopenings

Suppliers should use the Medicare Reopening Request FormPDF to mail or fax a Reopening request. If you wish to send a written request instead of using the Medicare Reopening Request Form, be sure to include the following information with your reopening request:

  • The beneficiary's name
  • The beneficiary's Medicare Beneficiary Identifier (MBI)
  • The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
  • The printed name of the person filing the request

For further assistance, read Chapter 13 of the DME MAC JC Supplier ManualPDF

The mailing address for written reopenings is:

CGS – Jurisdiction C Written Reopenings
PO Box 20010
Nashville, TN 37202

For a reopening with an underpayment, fax the request to 615.782.4649. For a reopening with an overpayment, fax the request to 615.782.4477.

Note: You can access the very same Reopenings Form within the myCGS web portal and submit your request online. This method is fast, easy, and paperless. Read more.

Resources

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