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Regulatory MonitoringTip: Understand the difference between a Medicare appeal and a Medicare reopening
By Deborah K. Hale, CCS
When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.
If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.
Valid reopening errors include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- 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
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On January 16, 2009, the Centers for Medicare & Medicaid Services released Transmittal 1671, which revises part of the Medicare Claims Processing Manual (Pub. 100-04) and addresses what constitutes new and material evidence as it relates to good cause for reopening a Medicare claim. See the Medicare Update weblog’s post at http://medicareupdate.typepad.com/medicare_update/2009/01/reopeningmedicareclaims.html