A clerical error reopening is a process that allows you to change claim data without submitting a written appeal. You can fax a clerical error reopening form. You cannot submit a reopening to add items or services not previously billed.
A clerical error reopening is defined per the CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 34 - Reopening and Revision of Claim Determinations and Decisions, section 10.6:
The claim can be reopened within one year from the date of the initial determination or redetermination for any reason or within four years from the date of the initial determination or redetermination for good cause:
See section 10.11 of this chapter to review definition of good cause.
Good cause documentation must accompany the reopening.
The clerical error reopening process does not replace the submission of an adjustment or corrected claim via direct data entry (DDE) in the Fiscal Intermediary Shared System (FISS). Submit a DDE adjustment whenever possible since it is the most efficient way to correct simple errors. Complete a Medicare Part A redetermination/clerical error reopening request form only for those situations where you are unable to do the DDE adjustment.
An accepted request for a claim reopening will result in a new remittance advice notification, which will list the new DCN for the adjusted claim. If the request for a claim reopening is not approved, you will receive a letter notifying you of the decision.
Clerical error reopening
*Remember to submit with a revised CMS-1450 (UB-04) claim form
Not clerical error reopening
*Must submit a redetermination request
Corrected diagnosis code or procedure code that makes the services(s) in question payable
Additional or revised diagnosis, modifier, units, or dates of service
Contractor error causing the claim to deny incorrectly due to an edit (claims were not mass adjusted by the contractor)
You indicate that an error was made that resulted in an overpayment
A change in billed charges
Services requiring the review of medical documentation
Adding the GA modifier
Unprocessable/returned claim (submit a new claim)
Adding claim lines (submit as a new claim or adjustment)
A redetermination is a written request, for a first level appeal, to the Medicare administrative contractor to review claim data when you are dissatisfied with the original claim determination. The redetermination is an independent process to re-evaluate the claim. To submit a redetermination request, please complete the Medicare Part A redetermination/clerical error reopening request form.
All written redetermination requests must contain the following:
The beneficiary name
The beneficiary Medicare number
The specific service(s) and/or item(s) for which the redetermination is being requested
The specific date(s) of service
An accepted request for a redetermination will result in a new remittance advice notification which will list the new DCN for the adjusted claim. If the request for a redetermination is not approved or unfavorable, you will receive a letter notifying you of the decision.
Requesting a redetermination
Time limit for a redetermination
Medicare redetermination notice
In order to file a redetermination, the claim must be in a finalized location as either processed or denied.
Claims that are considered to be unprocessable (missing, incomplete, or invalid information which is needed to process the claim) cannot be appealed, thus causing the redetermination to be returned to you with a letter of unacceptance.
You have 120 days from the date of the initial determination of the claim to file a redetermination.
We have 60 days upon receipt of the redetermination request to make a decision.
We will send a Medicare redetermination notice letter for all redetermination decisions that are fully or partially favorable as well as partially or fully unfavorable.
Redeterminations can be filed for the following with supporting documentation:
Redeterminations cannot be filed for the following:
Dissatisfaction with the initial claim determination
Medical review denials by Novitas and outside contractors such as recovery auditor, Comprehensive Error Rate Testing program, unified program integrity contractors, zone program integrity contractor, Office of Inspector General, etc.
Medically denied claim or denied line item on a claim
Returned to provider,
Rejected claims with tape-to-tape (TT FL field on the FISS claim summary screen) flag X (must correct or resubmit claim)
Claims denied for timely filing (exceptions may apply if guidelines are met)
Redetermination is unfavorable - follow appeal process and file reconsideration (2nd level appeal)
Tutorial: Completing the Medicare Part A redetermination and clerical error reopening request form
A general inquiry is a written correspondence initiated by you that includes questions related to Medicare billing, processing, or payments. There may be times when a redetermination cannot be accepted, and the request will be forwarded to the general inquires department for a response to you. We will send you a letter explaining why the appeal was not accepted. At this point, if applicable, you can file a new redetermination if it's within the 120-day timeframe.
If a redetermination is not accepted and sent to general inquires it must meet privacy requirements or it may not process. The privacy requirements include:
Last five digits of Tax ID
Date of birth (this is not required on a redetermination request form)
Date of service
Common issues handled as a general inquiry may include:
Questions regarding a claim that has not finished processing
Questions regarding a claim that did not complete processing and the system returned it to you for correction
Overlapping claims questions
General or policy questions
Timely claim filing questions
Financial questions (overpayments and demand letters)
Duplicate remittance advice requests
If all the services in question were paid (other than reduced DRG or RUG payment) and the appellant is not requesting a change to any of the lines
IRF-PAI late transmission penalty waiver requests and questions
Coordination of benefits Issues / Medicare secondary payer claims issues
Health maintenance organization, home health and other entitlement rejections
When to submit a new claim
When not to submit a new claim
No claim on file when checking claim status
Claim is unprocessable/returned (MA-130)
Denied/finalized claim on file
Claim data needs corrected/updated by adjusting the claim