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 may request that Palmetto GBA reopen the claim so the error or omission can be corrected rather than going through the written appeals process. Reopenings may be submitted in written form or in some cases over the telephone.

NOTE - Claims that are rejected as unprocessable (remark code MA130 on the remittance advice) cannot be reopened. Rejected claims must be corrected and resubmitted as a new claim.

What is considered minor errors or omissions and can be reopened:

  • Incorrect units of Medically Unlikely Edits (MUE) submitted on a claim
    • Correct units billed within the MUE
    • Reopen a date of service due to receiving two claims for the same service during the same processing period, one claim denied as duplicate and one claim denied for frequency
  • Transposed diagnosis or procedure codes
  • Incorrect submitted amount (if it will allow additional payment for the procedure billed) 
  • Change date of service (month and day only)
  • Submission of a claim for services that were not rendered
  • Incorrect rendering provider on claim (must verify the PTAN and NPI is associated with the billing group on the claim)

Did you know these are specific modifiers that are considered simple claim corrections? 

CPT ModifiersHCPCs Modifiers
25, 26, 50, 51, 54, 57, 58, 59, 76, 77, 78, 79, 91  AA, AD, AT, E1, E2, E3, E4, G8, G9, GV, GW, LT, KD, QJ, QK, QW, QX, QY, QZ, Q3, RT, TC, XE, XP XS and XU 

These modifiers can be added or deleted to a procedure as a simple claim correction when the correction will change the outcome of the overall claim.

Can I request a reopening using the Interactive Voice Response (IVR) system or through eServices?
Yes, procedure codes that have denied for coverage due to missing modifiers 25, 59 or 79 can be reopened using the IVR or eServices. 

Should I Assume Everything Else Must Be Submitted In Writing?
Yes, claims reopening process is specifically for simple corrections or omissions that do not require additional documentation. More complicated issues must be submitted in writing. The redetermination form is used for the 1st level appeal and the reconsideration form for the 2nd level appeal. Issues that should not be requested as reopenings include:

  • Situations involving 'Limitation of Liability' (issues involving Advance Beneficiary Notices)
  • Claims denied for LCD or NCD (medical necessity)
  • Claims that require operative reports and/or clinical summaries (surgery claims submitted with CPT modifier 22)
  • Claims that require medical review from our medical staff 
  • HCPCS modifiers AS and KX, CPT modifiers 80, 82, 52 and 24  
  • Requests to add items or services not originally submitted to Medicare
  • Hospice claims with dates of service that fall outside of the hospice period
  • Procedures considered to be once in a lifetime (e.g., G0438 and G0439)
  • Situations involving changes to the patient’s Medicare Secondary Payer records*
    • *If your claim denied indicating Medicare is secondary and both local (Palmetto GBA) insurance files and Common Working File (CWF) are updated to show Medicare is primary, this can be adjusted on the Reopening line  

There may be instances where an issue cannot be resolved as a reopening (telephone or written). An issue may not be resolvable because:

  • The issue becomes too complex to be handled as a reopening and/or it is in the best interests of the party to have a more in-depth review performed
  • There is a need for additional medical documentation from the provider, physician or other supplier
What Else Should I Know About Reopening Claims?
  • When calling the Telephone Reopening Line please be prepared to provide the provider's identifier, the patient's Medicare number, last name and first initial
  • Three qualified reopening requests will be allowed per phone call
  • This is not to be confused with the 2nd level appeal, Reconsideration. Reconsiderations are handled by a separate contractor, the Qualified Independent Contractor (QIC).
  • Remember, rejected claims (MA130) must be resubmitted as new claims and do not qualify for reopening

Telephone reopening hours of operation are Monday through Friday
8:30 a.m. — 12 p.m. open
12 — 1 p.m. closed
1 — 4:30 p.m. open

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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