Types of Reopenings
Clerical Error Reopenings
The Centers for Medicare & Medicaid Services (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
- 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
Clerical errors or minor errors are limited to errors in form and content, which does not include failure to bill for certain items or services. Palmetto GBA will not add items or services, based on a reopening request, that were not previously billed, except for a few limited items that cannot be filed on a claim alone, e.g., HCPCS codes G0369, G0370, G0371 and G0374.
Third party payer errors are not considered clerical errors.
If there is a medically denied line item on the claim, the Fiscal Intermediary Shared System (FISS) should not allow you to complete the adjustment electronically.
On January 1, 2016, CMS implemented the automated Clerical Error Reopening (CER) process, which allows providers to perform a reopening electronically. When correcting a claim with a medically denied line, it is important to key the lines as non-covered. Failure to do this will result in the claim being denied. CMS will not allow Direct Data Entry (DDE) claims that have been fully denied to be reopened. Providers must appeal these claim denials.
Palmetto GBA encourages providers to use the CER process. Instructions for the process are listed below:
If providers are unable to use the automated CER process, submit a Redetermination: 1st Level Appeal request form stating that you are requesting a clerical error reopening.
Claim Reopenings Beyond One Year
When the need for a correction is discovered beyond the claims timely filing limit, an adjustment bill is not allowed, and a provider must utilize the reopening process to remedy the error.
A reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are different from adjustment bills in that adjustment bills are subject to normal claims processing timely filing requirements (that is, filed within one year of the date of service), while reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed (for example, claim determinations may be reopened within one year of the date of the initial determination for any reason, or within one to four years of the date of the initial determination upon a showing of good cause).
Note that while the reopening period associated with ARC (adjustment reason code) R1 (one past the remittance advice date) is one year from the Remittance Advice date, providers must submit an adjustment bill (TOB xxx7) when the claim correction is submitted within the claims timely filing period (that is, within one year of the date of service or claim through date). The reopening request (TOB xxxQ) should only be utilized when the submission falls outside of the period to submit an adjustment bill.
Reopenings are also separate and distinct from the appeals process. A reopening will not be granted if an appeal has been requested, and a decision is pending or in process. Decisions to allow reopenings are discretionary actions on the part of your A/MAC. A MAC’s decision to reopen a claim determination or refusal to reopen a claim determination is not an initial determination and is therefore not appealable. Requesting a reopening does not guarantee that request will be accepted, and the claim determination will be revised, and does not extend the timeframe to request a Redetermination. If a MAC decides not to reopen an initial determination, the MAC will Return to Provider (RTP) the reopening request indicating that the MAC is not allowing this discretionary action. In this situation, the original initial determination stands as a binding decision, and appeal rights are retained on the original initial determination. New appeal rights are not triggered by the refusal to reopen, and the filing timeframes to request a Redetermination (which are based on the original initial determination) are not extended and do not “reset” following a contractor’s refusal to reopen. However, when a MAC does reopen and revises an initial determination, that revised determination is a new determination with new appeal rights.
- The claim correction process only applies to RTP claims. A claim correction may be submitted online via the Direct Data Entry (DDE) system.
- To access RTP claims in the DDE Claims Correction screen, select option 03 (Claims Correction) from the Main Menu and the appropriate menu selection under Claims Correction (21 – Inpatient, 23 – Outpatient, 25 – SNF)
- RTP claims remain in this location (TB9997) and are available for correction for 180 days
- RTP claims are not finalized claims and do not appear on your Remittance Advice (RA). Therefore, correct the claim in DDE (xx7). Remember you cannot correct a medically denied line. You must leave those as non-covered and make necessary corrections. Once the claim processes, you may appeal any denied lines.
- You should only submit a new claim if your situation falls within the exceptions below:
- You do not have access to the DDE system
- The RTP claim is not corrected within 180 days (or no longer appears in the Claim Correction screen) and becomes inactive (IB9997)
- The RTP claim was suppressed in error
Note: These claims cannot be suppressed.
DDE User’s Guide (PDF).
Adjustments or Cancels
Submitting an adjustment or a cancel to a claim can be submitted electronically or via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). In addition to the usual claim information, below you will find what fields are required on the UB-04 and in FISS DDE on adjustments and cancel claims. For additional information about adjusting and canceling claims using FISS DDE, refer to the FISS DDE Guide, Chapter Five: Claims Correction.
Adjustment claims (type of bill XX7) are submitted when it is necessary to change information on a previously processed claim. The change must impact the processing of the original bill or additional bills in order for the adjustment to be performed. The claim being adjusted must be in a finalized status location, i.e., P B9997 or R B9997.
If a claim in a P status has been reviewed by Medical Review and has one or more line items denied, adjustments can be made to the paid line items. Please note: Adjustments cannot be made to any part of a denied line item on a partially paid claim.
In addition, only rejected claims (R B9997) that have posted information to the Common Working File (CWF) should be adjusted, such as a claim that rejected due to an open Medicare Secondary Payer (MSP) record or a home health date of service that overlaps a beneficiary's stay in an inpatient facility.