Home Health and Hospice Claim Correction Reopenings

Published 11/20/2023

When the need for a claim correction is discovered and the claim is beyond the timely filing limit (one calendar year from the 'through' date on the claim), a reopening request (type of bill (TOB) XXQ) must be submitted to remedy the error. When a claim needs correction and the claim is within the timely filing limit, an adjustment (TOB XX7) may be submitted.

Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of Palmetto GBA. Minor errors or omissions may include:

  • Transposed procedure/diagnostic codes
  • Incorrect provider number or date of service
  • Inaccurate data entry
  • Mathematical or computational mistakes

Note: A reopening may be requested to change a claim determination that resulted in an overpayment or underpayment, even though the decision was correct when the claim was processed. Omissions do not include failure to bill items/services, such as late charges. Reopening submissions that attempt to add items/services will be returned. 

Reopenings are separate from the appeals process, and therefore, do not count towards the five levels of appeal. A reopening request cannot be submitted if an appeal has been requested, and a decision is pending or in process.

For reopening requests entered via Direct Data Entry (DDE), from the Fiscal Intermediary Standard System (FISS) Main Menu, select Claims Correction (Option 03), then, select the Claim Adjustments options 33 (home health) or 35 (hospice). In addition to the usual field locators and the information being adjusted, reopenings (TOB XXQ) must include the following information. If there is a medically denied line item on the claim, FISS may not allow you to complete the adjustment electronically.

Reopenings (TOB XXQ) cannot be submitted with a hardcopy (paper) UB-04. They must be submitted via the 5010 format or entered directly via DDE.

Field Name/Requirement

Description

TOB

(FISS Page 1)

32Q – home health reopening

34Q – home health outpatient reopening

81Q – hospice (nonhospital based) reopening

82Q – hospice (hospital based) reopening

 

Once the claim being reopened is selected, you must change the third digit of the TOB field to 'Q' to identify the adjustment claim as a reopening request.

COND CODES

(FISS Page 1)

Enter the appropriate condition code.

R1 – Mathematical or computational mistake
R2 – Inaccurate data entry
R3 – Misapplication of a fee schedule
R4 – Computer errors
R5 – Incorrectly identified duplicate
R6 – Other clerical error or minor error or omission (failure to bill a service is not considered a minor error)
R7 – Correction other than clerical error
R8 – new and material evidence is available
R9 – Faulty evidence (initial determination was based on faulty evidence)

COND CODES
(FISS Page 1)

Enter a condition code that best describes what is being changed.

 

D0 – Changes in service date

D1 – Change to charges

D2 – Changes in revenue code/HCPCS/HIPPS Rate Codes

D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes

D9 – Change in condition codes, occurrence codes, occurrence span codes, provider ID, modifiers and other changes

E0 – Change in patient status

 

When D9 is used, an explanation must be included in the REMARKS filed (DDE Page 4).

COND CODES

(FISS Page 1)

Enter 'W2' (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process. A reopening request cannot be submitted if an appeal has been requested, and a decision is pending or in process.

ADJUSTMENT REASON CODE

(FISS page 3)

FISS will automatically assign one of the codes below.

R1 – Less than 1 year from the initial determination (Remittance Advice (RA) date)

R2* – 1–4 years from the initial determination (RA date)

R3* – Greater than 4 years from the initial determination (RA date)

 

*Requires "Good Cause" to be documented by submitting a "Remark".

REMARKS

(FISS page 4)

Remarks are always helpful in processing a reopening; however, the REMARKS field is required when the R2 or R3 Adjustment Reason Code is submitted. Remarks should be formatted for a change or addition (C-A), new and material evidence (NME) and faulty evidence (F-E) with a narrative explanation.

 

NOTE: The first 15 characters of the remark must match exactly as shown below.

 

Good_Cause-_C-A (underline indicates a space)

Good_Cause-_NME (underline indicates a space)

Good_Cause-_F-E (underline indicates a space)

Example: Good Cause- C-A to add revenue code 0550 because…

 

If the change or addition affects a line item, please indicate which line(s) is/are being changed.

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