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Jurisdiction 1 Part B
Reopenings (Claim Corrections) and Appeals: Tips for Faster Service

Palmetto GBA processes 'reopenings' (claim corrections) and redetermination requests (first level appeals) for all Jurisdiction 1 providers, including requests related to claims that were processed by the previous contractors. 
 
We are committed to providing you with the best possible service for these requests. To ensure that we are able to handle your requests for reopenings and redeterminations correctly and efficiently, please include a copy of your original remittance notice and any other written communication from the previous contractor, such as an automated development request (letter), with all written requests for reopenings and redeterminations. 
 
Reopenings
As a reminder, you may request a reopening for situations that meet the following criteria as 'minor omissions and corrections.'  You may also request a reopening by telephone for claims that meet these criteria.
  • Mathematical or computational mistakes
  • If you submitted the incorrect number of units (i.e., 1 unit instead of 10 units in item 24G or its electronic equivalent), please be sure to adjust the billed amount, if necessary)
  • Transposed procedure or diagnosis codes
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Duplicate denials, when you believe that the 'duplicate' denial is incorrect (i.e. two (2) ambulance transports same modifiers on both transports but at different times of day)
  • Incorrect data items, such as rendering provider within same group, date of service (month and day only – unable to change the year of service)
  • Adding and/or removing of modifiers from procedure codes that do not require additional documentation
The following modifiers can be corrected through a Claim Reopening:

CPT Modifiers
HCPCS Modifiers
21, 25, 26, 50, 51, 54, 57, 58, 59, 66, 74, 76, 77, 78, 79, 80, 82
AA, AD, AT, E1, E2, E3, E4, G8, G9, GV, GW, LT, KD, KX, QJ, QK, QR, QW, QX, QY, QZ, Q3, RT, SG, TC
 
The following types of situations/denials cannot be addressed through a reopening request:
  • Services that have been rejected with remark code MA130 (claims for services rejected with this remark code must be corrected and resubmitted as new claims)
  • Services subject to Limitation of Liability (e.g., issues involving Advance Beneficiary Notices)
  • Claims denied or reduced due to medical necessity
  • Claims that require operative reports and/or clinical summaries (for example, surgery claims submitted with CPT modifier 22)
  • Claims requiring the input of our medical staff or other entities outside of the reopening department and 'big box' cases
  • Requests to add items or services not originally submitted to Medicare (file these services as new claims)
 
Redeterminations
If your claim denial does not meet the reopening criteria, please submit a Redetermination Request using the form on the Palmetto GBA J1 Web site. 
  • You must file a Redetermination Request before pursuing other levels of appeal, such as Reconsiderations
  • Time Limit-Requests for redetermination must be made in writing within 120 days from the date of the initial claim determination
  • Supporting Documentation-Ensure timely responses to your appeal requests by submitting the additional documentation needed to support payment of your claim or services. This includes any office notes and/or reports. It is also important to use the proper form for the type of appeal for which you qualify and are requesting.
  • Form- Although the redetermination request form is not required, we strongly recommend that you use this form to request a redetermination. This will help ensure that your request reaches the correct area as quickly as possible.
Resources
  • Palmetto GBA Telephone Reopening Line (Part B): (866) 669-5543 (hours: 7 a.m. to 3 p.m. PST)
  • Send written requests for reopenings (including a copy of your original remittance notice) to and written requests for redeterminations (including the remittance notice and additional supporting documentation as appropriate) to:
Palmetto GBA – J1 MAC
P.O. Box 1252
Augusta, GA 30903-1252

 

last updated on 10/02/2008
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