Reopenings for Minor Errors and Omissions
Overview
Suppliers should be aware 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. In the case where a minor error or omission is involved, the supplier can request Medicare to reopen the claim so the error or omission can be corrected rather than having to go through the appeal process. You can request a reopening for minor errors or omissions either by telephone or in writing. 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
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer errors
- Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate.
- Incorrect data items, such as provider number, use of a modifier or date of service.
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 the supplier submit a written redetermination request.
The following issues cannot be handled as a Reopening:
- Redetermination requests, which must be submitted via the appeals process
- Untimely filing – Reopenings Requests must be made within one year from the date of initial determination
- Unprocessable/Returned claims (i.e. ANSI code 16)-resubmit the claim with the corrected information
- Addition, change, and/or removal of KX, GA, GY and/or GZ modifiers
TopTelephone Reopenings
The DME MAC telephone reopening number is 1-866-813-7878. This line is in service Monday through Friday, from 8 AM to 10:30 AM and from 12 PM to 3:30 PM, Central Standard Time.
Use the telephone reopening process to resolve minor errors or omissions involving:
- Units of service
- Service dates
- Healthcare Common Procedure Code System (HCPCS) coding
- Diagnosis codes and diagnosis reference
- Modifiers (excluding the KX, GA, GY and/or GZ modifier)
- Place of service
- Claim incorrectly denied as duplicate charges
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.
Questions about the status of a claim, or general Medicare payment and coding questions, should not be directed through the telephone reopening line. Suppliers can obtain a claim status report through the Interactive Voice Response (IVR) Unit or by using 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
- Beneficiary name and Medicare health insurance claim number (HICN)
- Any additional information to support why you believe the decision is not correct. This includes having the correct procedure code(s), modifier(s), diagnoses, 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, a redetermination must be made in writing.
To effectively service all callers, each call is limited to five claim issues.
The following issues cannot be handled by the telephone reopening representative:
- Redetermination requests, which must be submitted via the appeals process
- Untimely filing – Reopenings Requests must be made within one year from the date of initial determination
- Unprocessable/Returned claims (i.e.CO-16 denials)
- Medicare Secondary Payer (MSP) 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 on the status of a claim(s)
- Inquiries related to denial of payment based on entitlement
- Questions that are general in nature and not claim specific
- Reopenings requests for break in service issues
- CMN or DIF issues or changes
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
Mailing Address
Written requests for reopenings should be mailed to:
CIGNA Government Services DME MAC Jurisdiction
C
ATTN: Clerical Error Reopening Department
PO Box 20010
Nashville, TN 37202
Fax Number
Written requests for reopenings may also be faxed. For a reopening with an underpayment fax to: 615.782.4649. For a reopening with an overpayment fax to: 615.782.4477
Instructions
Written Reopening requests should be made using the Medicare Reopening Request form found on our Forms page. 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 Medicare health insurance claim number of the beneficiary
- 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 and signature of the person filing the request
For further assistance, please consult Chapter 13 of the DME MAC Jurisdiction C Supplier Manual.
Forms
Reopenings forms, including the Redetermination Request Form and the Reopening Request Form can be found on our Forms page.
