Medicare denial - Telephone Reopening




Telephone reopening shall be limited to resolving minor issues and correcting errors. As necessary, the contractor may ask the provider, physician, or supplier to fax in documentation to support changes and error correction. If it appears extensive documentation is required for review, the requestor may be informed that they should file a written request for reopening or file a request for an appeal, if applicable.

Telephone reopening can be performed on the following:

* Mathematical/computational errors (e.g., obvious errors of miscoding the allowed amount as $10.00 vs. $100.00)

*  Transposed diagnosis and procedure codes

* Inaccurate data entry (e.g., scanner errors, billed amounts, dates of service, place of service)

* Carrier Errors

*  Addition of an add-on procedure code (e.g., codes with global days of ZZZ)

* Misapplication of fee schedule (generally due to changes in the fee schedule amounts)

* Inaccurate duplicate denial (not a true duplicate)

*Incorrect performing provider identification number in Item 24K (Missing performing provider PIN’s are rejected, and must be resubmitted)

*  Ambulance (correct transposed zip code; correct origin/destination modifiers for obvious errors such as HS)

* Modifier additions: limited to modifiers 24, 25, 26, 57, 78, 79, TC, KX, GV, GW, QW, QB, QU, AR, AQ, AT, SG (Note: All other modifier additions must be sent to Re-determination).


If the claim is rejected/unprocessable due to provider error, then the provider must resubmit their claim. Reopenings that are too complex to be corrected over the phone or that require substantial additional medical documentation to resolve, may be submitted in writing to the carrier. Due to CMS telephone inquiry service level requirements, the number of corrections handled during a phone call may be limited. If you have a large volume of corrections, for example an error repeated for numerous claims in the same billing cycle, the request is best handled in writing. The above list is subject to change.


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