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South Carolina Part B Carrier
Instead of a Written Redetermination: Consider Having your Claim Reopened!

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, such as:
  • Mathematical or computational mistakes
    • If you submitted an incorrect number of units (e.g., 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 (exception: ambulance trips denied as duplicates, when there are two identical trips on the same day)
  • Incorrect data items, such as provider identifiers, use of a modifier or date of service (month and day only)
  • Adjustments to claims that were submitted in error that will result in an overpayment. Palmetto GBA will initiate the overpayment process when you notify us that this situation has occurred.
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. The following modifiers can be corrected through a Claim Reopening: 
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, GV, GW, LT, KD, KX, QJ, QK, QR, QW, QX, QY, QZ, Q3, RT, SG, TC

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 (the Redetermination form for 1st level appeal; Reconsideration form for a 2nd level appeal). This includes:
  • Situations involving ‘Limitation of Liability’ (i.e., 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
  • Reopenings that will result in overpayment requests
What else should I know about reopening claims?
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).
  • To ensure you have all information needed to have your claim reopened, refer to the Denial Finder tool for South Carolina Part B 
  • Three qualified requests will be allowed per phone call
  • Remember, rejected claims (MA130) must be resubmitted as new claims and do not qualify for reopening
The Claim Reopening Line contact information:

Number to call: (866) 815-7891
When to call: Monday through Thursday, 9 a.m. to 12 p.m. and 1 p.m. to 3 p.m. (EST), or Friday from 9 a.m. to 12 p.m.

 

last updated on 08/06/2009
CMS