Instead of a Written Redetermination: Consider Having Your Claim Reopened

Published 05/02/2018

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 Railroad Medicare 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, over the telephone or through our eServices online portal.

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 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
  • Incorrect data items, such as provider number, use of a modifier or date of service (month and day only)
    • Incorrect rendering provider (correct provider must be associated with billing provider on claim)
    • Incorrect referring/ordering provider
  • 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.

Please 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 Telephone Reopening?
Yes. The following modifiers can be corrected through a claim reopening:

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

Can I request a reopening using the Interactive Voice Repose (IVR) system or through eServices?
Yes, procedure codes that were denied on National Correct Coding Initiative )(NCCI) edits or global surgery edits can be reopened using the IVR or eServices when the addition of CPT modifier 25, 59 or 79 is appropriate.

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 or omissions that do not require additional documentation. More complicated issues must be sent in writing using the appropriate form (the Redetermination form for first level appeal; Reconsideration form for a second level appeal). This includes:

  • Situations involving 'Limitation of Liability' (i.e., issues involving Advance Beneficiary Notices)
  • Claims denied for 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, such as ambulance transports, unlisted codes, or any claim requiring medical review of supporting documentation 
  • Requests to change liability from the provider to the beneficiary
  • Hospice claims with dates of service that fall outside of the hospice period
  • HCPCS modifiers AS and CPT modifiers 80, 82, 52, and 24
  • Claims containing physical therapy services
  • Once in a lifetime procedures
  • Situations involving changes to the patient’s Medicare Secondary Payer records*
    • * If your claim denied indicating Medicare is secondary and both the Common Working File and Palmetto’s records 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 interest 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 following:
    • Provider Transaction Access Number (PTAN)
    • Provider NPI
    • Provider’s last five digits of the Tax ID
    • The patient's Medicare number, last name and first initial
  • This is not to be confused with the second 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 for reopening

The Railroad Medicare Telephone Reopening Line Contact Information
Call 888-355-9165 Monday through Friday from 8:30 a.m. to 4:30 p.m. for all time zones, with the exception of Pacific Time, which receives service from 8 a.m. to 4 p.m.  For reopenings, first press 4, and then to request a telephone reopening to correct minor errors or omission, press 0. 

The Railroad Medicare Fax Reopening Line Information
You can submit your Reopening request by faxing your documentation to (803) 462-2218.

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