July 9, 2012 – Updated 08.09.21
Claim Reopening Versus Redetermination
Suppliers should be aware that there is no need to request a redetermination if the supplier has made a minor error or omission in filing the claim, which, in turn, caused the claim to be denied. When a minor error or omission is involved, the supplier can request that Medicare reopen the claim so the error or omission can be corrected, rather than going through the appeals/redetermination process.
IMPORTANT: You must follow the appeals process and submit supporting documentation for minor omissions and clerical errors IF the claim was denied as not reasonable and necessary or it was denied as a result of an audit or review. For these circumstances, you cannot request a reopening.
There are several methods to request a reopening:
- myCGS Claim Correction
- myCGS Reopenings Form Submission
- Telephone Reopening
- Written Reopening (mail or fax)
Suppliers have one year to request a reopening from the date on the remittance advice.
Examples of minor errors or omissions include:
- Mathematical or computational mistakes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer errors
- Incorrect data items such as provider number, use of a modifier, or date of service
- Claims that denied for missing or incomplete Certificate of Medical Necessity (CMNs) or DME MAC Information Form (DIFs)
- Accessories/supplies that denied for base equipment missing
Exceptions:
- 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
- To change, add, or remove modifiers KX, GA, GZ, and GY, claims MUST be appealed through redeterminations with supporting documentation
Resources:
The most efficient way to submit reopening and redetermination requests is through the myCGS online portal. View the myCGS Registration and Account Management Guide to register for your account today.
Please note that if a claim has been previously adjusted, you cannot submit a reopening or redetermination request through the myCGS web portal. You must submit the request in writing.
Jurisdiction C suppliers may submit their Reopening Request Form
via
Fax: 615.782.4649
Mail:
CGS Jurisdiction C
PO Box 20010
Nashville, TN 37202
Jurisdiction C suppliers may also contact telephone reopenings at 1.866.813.7878.
Jurisdiction C suppliers may submit their Redetermination Request Form via
Fax: 615.664.5907
Mail:
CGS Jurisdiction C
PO BOX 20009
Nashville, TN 37202
Utilize our Claim Denial Resolution Tool to determine your next step(s) following a claim denial. Keep in mind that this tool is available for claim denial assistance with the most common denials; however, it may not address every scenario.
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