Reopenings Adjustment Request Form
The Part B (not DME MAC) Reopenings Form is used to correct minor errors and omissions such as changing:
- dates of service
- places of service
- HCPCS/CPT codes
- numbers of service
- diagnosis codes
- modifiers
- submitted amounts
Reopening requests must be submitted within 12 months of the original claim remittance date. Please be advised, you should not use this form if the change you are requesting will result in an overpayment; i.e., changing a procedure code to one that has a lower allowed amount than the code that was previously allowed and paid on the original claim.
In addition, requests for claims that are rejected with the MA130 code should not be submitted on this form. Instead, these claims should be corrected and resubmitted as new claims.
*This form should not be used for Appeal requests.
