There is no need to appeal a claim if you have 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, you can request that Palmetto GBA reopen the claim so the error or omission can be corrected rather than going through the written appeals process.
What type of claims can be reopened?
Claims with minor errors and omissions can be reopened. This includes the following:
- Mathematical or computational mistakes
- If you submitted the incorrect units (i.e., 1 instead of 2 in item 24G or its electronic equivalent), please be sure to adjust the charge accordingly
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer errors
- Duplicate denials, when you believe that the 'duplicate' denial is incorrect
- Incorrect data items, such as provider identifiers, use of a modifier or date of service (month and day only)
NOTE: Claims that have been rejected as unprocessable (remark code MA130 on the remittance notice) cannot be reopened. Those claims must be corrected and resubmitted as new claims.
Are there specific modifiers that qualify for a Claim Reopening?
Yes. Modifiers that can be corrected through a Claim Reopening are:
| CPT Modifiers | HCPCS Modifiers |
| 21, 25, 26, 50, 51, 54, 57, 58,59, 66, 73, 74, 76, 77, 78, 79,80, 82 |
AA, AD, AT, E1, E2, E3, E4, G8, G9, LT, KD, KX, QJ, QK, QR, QW, QX, QY, QZ, Q3, RT, SG, TC |
I know what can be reopened so should I assume everything else must be submitted in writing?
Yes, that is a safe assumption. The Claim Reopening process is specifically for simple corrections. More complicated issues must be sent in writing using the appropriate form, which is the Redetermination form (PDF, 266 KB) for the 1st level appeal and the reconsideration form for a 2nd level appeal. This would include issues such as:
- 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 (e.g., 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
Are there any other noteworthy details?
Yes, there are:
- When calling the Claim Reopening area please be prepared to provide the provider's identifier, the patient's Medicare number, last name and first initial
- This is not to be confused with the 2nd level appeal, Reconsideration. Reconsiderations are handled by a separate contractor, the Qualified Independent Contractor (QIC).
- Three qualified requests will be allowed per phone call
- Remember rejected claims (MA130) must be resubmitted as new claims and do not qualify
Claim Reopening Line Contact Information
Telephone Number: (866) 324-3073
When to call: Monday through Friday, between 8:30 a.m. to 4:30 p.m. in all time zones except PST, which receives service from 8 a.m. to 4 p.m. PST.