(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 34 - Reopening and Revision of Claim Determinations and Decisions  (Rev. 4219, 01-25-19)  Table of Contents   Transmittals for Chapter 34   10 - Reopenings and Revisions of Claim Determinations and Decisions - General  10.1 - Authority to Conduct a Reopening 10.2 - Refusal to Reopen is Not an Initial Determination  10.3 - Reopening of Denials Based on an Unanswered ADR Request  10.4 - Reopenings Based on Clerical or Minor Errors and Omissions  10.4.1 - Providers Submitting Adjustments  10.5 - Telephone Reopenings  Required for A/B MACs (B)  Only  10.5.1 - Informing the Provider Communities About the Telephone Reopenings Process  10.5.2 - Issues for Telephone Reopenings  10.5.3 - Conducting the Telephone Reopening 10.5.4 - Documenting the Telephone Reopening 10.5.5  Monitoring the Telephone Reopening 10.6 - Timeframes to Reopen Claim Determinations  10.6.1 - Timeframes for Contractor Initiated Reopenings  10.6.2 - Timeframes for Party Requested Reopenings  10.6.3 - Timeframes for Adjudicator to Reopen  10.6.4 - Timeframes When a Party Requests an Adjudicator Reopen Their Decision  10.7 - Timeframes to Complete a Reopening Request by a Party  10.8 - Notice of a Revised Determination or Decision  10.9 - Revised Determination or Decision  10.10 - Effect of a Revised Determination or Decision  10.11 - Good Cause for Reopening 10.11.1 -  What Constitutes New and Material Evidence  10.11.2  Policies Related to Good Cause Reopenings for New and Material Evidence 10.11.3  What Constitutes Error on the Face of the Evidence  10.12 -  Change in Substantive Law or Interpretative Policy  10.13  System and Processing Requirements for Use of Secure Internet Portal/Application to Support Reopening Activities  10 - Reopenings and Revisions of Claims Determinations and Decisions - General  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A reopening is a remedial action taken to change a binding determination or decision that resulted in either an ov erpayment or an underpayment, even though the determination or decision was correct based on the evidence of record.  Reopenings are separate and distinct from the appeals process.  Reopenings are a discretionary action on the part of the contractor.  A co ntractors decision to reopen a claim determination is not an initial determination and is therefore not appealable.  Requesting a reopening does not toll the timeframe to request an appeal.  If the reopening action results in a revised determination, then new appeal rights would be offered on that revised determination.  Under certain circumstances a party may request a reopening even if the timeframe to request an appeal has not expired.  Historically, contractors have employed a variety of informal proce dures under the general heading of reopenings, re- reviews, informal redeterminations, etc.   Providers, physicians and suppliers may have come to view these as appeal rights. However, as stated above, reopenings are separate and distinct from the appe als process.  They are not a partys right.  Contractors shall not use them to provide an appeal when a formal appeal is not available.  Contractors should also note that while clerical errors must be processed as reopenings, all decisions on granting reopenings are at the discretion of the contractor.  Contractors may conduct a reopening to revise an initial determination or redetermination.  Medicare Secondary Payer (MSP) recovery claims where the debtor is the beneficiary or provider/supplier are not reopening actions except where the recovery claim is  a MSP provider/supplier recovery claim because the provider/supplier failed to file a proper claim as defined in 42 CFR Part 411 .  Aside from this one exception, MSP recovery claims involve recovery of the insurance funds at issue, not recovery of the payment previously made by Medicare.  Consequently, the recovery action does not involve the reopening of Medicare's payment determinati on.  The MSP recovery demand letter is an "initial determination" as defined in 42 CFR 405.924 , not a reopening and revision of Medicare's initial claims payment determination.   10.1 - Authority to Conduct a Reopening  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  Reopenings can be conducted by a contractor to revise  an initial determination, revised initial determination or redetermination; a Qualified Independent Contractor (QIC) to revise a reconsideration; an Administrative Law Judge (ALJ) to revise a hearing decision, and the Appeals Council (AC) to revise an ALJ  decision or their own review decision.   Reopenings are generally not conducted until a partys appeal rights have been exhausted or the timeframe to file a request for an appeal has expired.  There are two exceptions that allow a reopening to be conducted when appeal rights have not been exhausted or the timeframe to request an appeal has not expired.  These exceptions are:    Cases where Medical Review (MR) requested documentation, did not receive it, and issued a denial based on no documentation (i.e., Gro up Code: CO -  Contractual Obligation; Claim Adjustment Reason Code (CARC) 50 -  these are non-covered services because this is not deemed a medical necessity by the payer; and Remittance Advice Remark Code (RARC) M127 -  Missing patient medical record for this service ).  Subsequently, if the party requests an appeal and submits the requested documentation with that appeal, it shall be treated as a reopening; and    Clerical errors (which includes minor errors and omissions) shall be treated as reopenings.  If a contractor receives a valid and timely request for redetermination and begins processing the request as a reopening (clerical error or otherwise) and later determines that a reopening cannot be performed, or the determination cannot be changed, the contractor shall not issue a refusal to reopen notice.  Rather, the contractor shall process the request as a valid/timely redetermination (as originally requested by the party) in accordance with Pub. 100- 04, chapter 29.   If a party has filed a valid request  for an appeal, the adjudicator at the lower levels of the appeals process loses jurisdiction to reopen the claim on the issues in question.  For example, a party simultaneously requests a QIC reconsideration and a reopening with the contractor.  The contr actor can no longer reopen that redetermination decision now that the party has filed a valid request for QIC reconsideration.  This does not preclude contractors from accepting and processing remands from the QIC.   As stated previously, it is within the contractors discretion to accept reopening requests, but once accepted, they must be processed in accordance with the above instruction.  10.2 - Refusal to Reopen Is Not an Initial Determination  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implement ation: 11- 29-06)  A finding that a prior determination or decision will not be reopened is not an initial determination or decision.  A contractors choice not to reopen is not appealable.  Accordingly, the contractor shall not include a statement concerning the right to an appeal in the notice informing the party that their reopening request cannot be processed.  A party may however request an appeal on the original claim denial, but must do so within the required timeframes.  If a contractor recei ves a reopening request and does not believe they can change the determination, they should not process the request.  10.3 - Reopenings of Denials Based on an Unanswered Additional Documentation Request (ADR)  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  If a claim is suspended for medical review, an ADR may be issued to obtain information needed to make a determination.  Providers, physicians, and suppliers are responsible for providing the information needed to adjudicate t heir claims.  If no response is received to the ADR within the specified timeframes, the medical review department will likely deny the service as not reasonable and necessary based on a lack of documentation.  If such a denial is appealed, the Medical Rev iew department at the contractor shall perform a reopening instead of an appeal if all of the following conditions are met:   1) A provider failed to timely submit documentation requested through an ADR;   2) The claim was denied because the requested documentatio n was not received timely;   3) The requested documentation is received after the 45 day period with or without a request for redetermination or reopening; AND,   4) The request is filed within 120 days of the date of receipt of the initial determination.   If all 4 criteria are not present, the request is for a redetermination and it is submitted within 120 days of the date of receipt of the initial determination, handle it as an appeal and do not ship the case back to MR.  In this instance, the request must meet t he criteria for a valid request for redetermination (see Pub. 100- 04, Chapter 29, 310.1) in order for the appeals unit to accept the request.   The CMS is handling these requests outside of the appeals process because CMS wants to encourage providers, physicians and suppliers to submit documentation when requested in order to prevent unnecessary appeals.  Contractors should note that this requirement does not extend the time frame for filing an appeal.  Therefore, only those appeal requests that are sub mitted within 120 days of the date of receipt of the initial determination and meet all of the criteria above should be shipped back to MR for a reopening.  When the appeals unit ships cases back to the MR unit, MR must reopen those cases.   If the request is submitted after 120 days, contractors may grant a regular reopening at their discretion or dismiss the request if no good cause explanation is provided for the late filing.   If the ADR reopening results in an affirmation of the original denial or an adverse decision, the provider will retain their right to a redetermination.  The date of the MR decision will be the date used to calculate the 120 days to request a redetermination.  10.4 - Reopenings Based on Clerical or Minor Errors and Omissions  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  Section 937 of the Medicare Modernization Act (MMA) required CMS to establish a process, separate from appeals, whereby providers, physicians and suppliers could correct minor errors or omissions.  We equate the MMAs minor error or omission to fall under our definition of clerical error, located in 42 CFR 405.980(a)(3) .  We believe that it is neither cost efficient nor necessary for contractors to correct clerical errors through the appeal process.  Thus, 42 CFR 405.927 and 405.980(a)(3)  require that clerical errors be processed as reopenings rather than appeals.  CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:    Mathematical or computational mistakes;   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)