(Medicare Claims Processing Manual)

 Transposed procedure or diagnostic codes;    Inaccurate data entry;    Misapplication of a fee schedule;    Computer errors; or,    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.   Note that clerical errors or minor errors are limited to errors in form and content, and that omissions do not include failur e to bill for certain items or services.  A contractor shall not grant a reopening to add items or services that were not previously billed, with the exception of a few limited items that cannot be filed on a claim alone (e.g., G0369, G0370, G0371 and G037 4).  Third party payer errors do not constitute clerical errors.   The law provides that reopenings may be done to correct minor errors or omissions, that is, clerical errors.  The contractor has discretion in determining what meets this definition and ther efore, what could be corrected through a reopening.   10.4.1 - Providers Submitting Adjustments  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  Part A providers that are able to submit an adjusted or corrected claim to correct an error or omission may continue to do so and are not required to request a reopening.  Additionally, we encourage A/B MACs (A) and (HHH) who were handling the corrections of such errors by advising providers to submit adjusted claims to instruct provider s that submitting adjusted claims continues to be the most efficient way to correct simple errors.   10.5 - Telephone Reopenings - Required for A /B MACs  (B) Only (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  NOTE:  Since most A/B MACs (A) and (HHH) never processed telephone redeterminations, CMS does not expect that A/B MACs (A) and (HHH) will process many telephone reopenings, if any.  However, they are not precluded from doing so, should the telephone process prove  effective.  If A/B MACs (A) and (HHH) choose to process telephone reopenings, they will be held to the same standards.   The majority of appeals processed as telephone redeterminations consisted of minor or clerical errors that could be quickly corrected o ver the telephone.  Section 937 of MMA required CMS to establish a process to correct such errors outside of the appeals process.  Therefore, CMS has discontinued telephone redeterminations that were formerly processed by A/B MACs (B) and DME MACs and has implemented the telephone reopenings process.  CMS believes that the vast majority of the work processed as telephone redeterminations can instead be processed as telephone reopenings.  A small percentage of the work processed under telephone redeterminati ons will now fall under written redeterminations and stay within the purview of the appeals units.  A/B MACs (B) and DME MACs shall allocate costs of reopenings that would have formerly been processed as a telephone redetermination, but fall under the defi nition of a clerical error under the claims reopenings Budget & Performance Requirements (BPR) Code (11210).  ADR reopenings that are shipped back to MR should be counted in the appropriate MR BPR code.  The following sections describe the procedures for accepting and processing reopenings over the telephone.  CMS believes that most telephone reopenings will consist of clerical errors or omissions that can be corrected quickly and easily over the telephone.  That does not preclude contractors from processin g written requests for clerical error reopenings.  They may handle such requests either by phone or in writing.   Whether a request for reopening is made by telephone or is conducted and completed as a telephone reopening depends on the issues at hand and the complexity of the matters involved.  Receiving reopening requests and conducting reopenings on the telephone should expedite and simplify the process.  Requesting a reopening on the telephone provides quick and easy access to parties who wish to correc t clerical errors or omissions.   The contractor shall ensure that the Privacy Act of 1974, 5 USC, 552a , is applied to its telephone reopening process.  All staff that perform telephone reopenings shall be trained on the Privacy Act requirements (see Pub. 100- 01, chapter 6, Disclosure of Information).   10.5.1 - Informing the Provider Communities About the Telephone Reopeni ngs Process (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  The contractor shall inform providers, physicians, and other suppliers of its telephone reopenings process 30 days prior to initiation and annually thereafter or when making significant changes to its process.  It shall provide information about its process through means such as Web sites, bulletins/newsletters, customer service/inquiry and provider relations departments, conduct seminars, etc.   Information it publishe s about its telephone reopenings process should include:    How to access the process (telephone number, hours of operation, etc.);    Any limitations (such as certain issues, number of claims/issues per call, etc.);   Specific instructions that the party should state that he/she is requesting a telephone reopening;    Type of documentation that the party should have on hand when calling in to request a reopening;    The types of issues the contractor might be able to handle over the telephone and the types of issues it will not handle over the telephone.  Please see 10.5.2 below for further discussion of issues that are appropriate for telephone reopenings.   10.5.2 - Issues for Telephone Reopenings  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  Telephone reopenings shall be limited to resolving minor issues and correcting errors as defined in 10.4.  As necessary, the contractor may ask the provider, physician, or supplier to fax in documentation to support changes and error correction.  If it appears extensive documentation is required for review, please inform the requestor that they should file a written request for reopening or file a  request for an appeal, if applicable.   Telephone reopenings are generally inappropriate  for the following issues:    Limitation on liability;    Medical necessity denials and reductions; or    Analysis of documents such as operative reports and clinical summar ies.  Contractors are not precluded from conducting a reopening on the issues listed above.  However, CMS believes that the issues above are usually too complex to be handled appropriately over the phone in most instances.  In all cases, telephone reopenings are inappropriate  for the following issues:  Claims requiring the input of medical staff or other entities outside of the reopenings department and big box cases.   A.  Issues That Can Not be Resolved During the Telephone Reopening   There may be instances where an issue cannot be resolved during the telephone reopening.  An issue may not be resolvable on the telephone because: (1) the issue becomes too complex to be handled over the telephone and/or it is in the best interest of the party to have a more in -depth review performed; or (2) there is a need for additional medical documentation from the provider, physician, or other supplier.   If the issue cannot be resolved due to one of the preceding reasons, the contractor advises the party that the r eopening cannot be handled over the telephone.  The contractor shall instruct the party to either file a written request for reopening or file a written request for appeal.  Instruct the party that appeal requests must be filed within 120 days from the date of the initial determination.   10.5.3 - Conducting the Telephone Reopening  (Rev.  4219, Issued: 01- 25-19, Effective: 02- 26-19, Implementation: 02- 26-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Prior to conducting a telephone reopening, the caller must provide the following three items:   Verify the providers/physicians/suppliers name and identification number or National Supplier Clearinghouse number;    Beneficiary last name, first initial; and    Medicare number .  Items must match exactly.   The contractor should also inform the caller that the call may be monitored for quality assurance.   The following items shall be obtained/recorded/confirmed during telephone reopening:    Date of call;    Name of caller;    Phone number of the party;    Name of provider/physician/supplier of item or service;    Dates of service;    Which items(s) or service(s) are at issue;    Reason for the request;    Any new information that is received during the telephone call;    Rationale for not processing the request, if applicable;    Any appeal rights, if applicable ;   Name of the reviewer;    Confirmation number, if applicable; and    Inform the caller that the call may be monitored.   10.5.4 - Documenting the Telephone Reopening  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  The information received during the telephone reopening (especially the date of the call) must be either: (1) documented on a reopening documentation form; or (2) logged into the contractors computer system.   All documentation must be assigned a control number. Any additional documentation received must be recorded into the contractor system or attached to th e form.  The telephone reopening control number is recorded on all documents received that are associated with the telephone reopening, if applicable.  The documents are included in the file.   Although documentation should rarely be necessary during a tele phone reopening, the documentation must be made a part of the file and be available if an appeal is requested based on any revised determination issued as a result of the reopening.  All documentation should be maintained in a manner that allows for future  audits.  10.5.5 - Monitoring the Telephone Reopening  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  CMS may review this function at any time so the contractor may want to develop and maintain records on a monitoring/quality assurance process.   10.6 - Timeframes to Reopen Claim Determinations  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  Our regulations establish timeframes that restrict the ability of the contractor to reopen claim determinations.  See 42 CFR 405.980(b) and (c)  for the timeframes for reopenings.  The specific timeframes for contractor -initiated and party -requested reopenings are detailed below.   10.6.1 - Timeframes for Contractor Initiated Reopenings  (Rev. 3568, Issued: 07- 29-16, Effective: 09 -30-16, Implementation: 09- 30-16)  A contractor may reopen and revise its initial determination or redetermination on its own motion:    Within 1 year from the date of the initial determination or redetermination for any reason; or    Within 4 yea rs from the date of the initial determination or redetermination for good cause as defined in 10.11; or    At any time if:   o There exists reliable evidence that the initial determination was procured by fraud or similar fault as defined in 42 CFR 405.902 ; or  o The initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based.  Third party payer error does not constitute clerical error as defined in 10.4; or,   At any time to effectuate a coverage decision issued under 42 CFR 426.460(b)(1)(i) , 426.488(b) and (c)  or 426.560 (b)(1)(i)  appeals process.   10.6.2 - Timeframes for Party Requested Reopenings  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A party may request a contractor reopen and revise its initial determination or redetermination under the following conditions: