Reopening vs. Redetermination

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established a
process for physicians, providers, and suppliers to correct minor error and omissions in claims
without pursuing the formal appeal process. Reopenings were established for this purpose

The purpose of a reopening is to change the determination or a decision that resulted in either an
overpayment or an underpayment. It is considered a discretionary action as defined by the Code
of Federal Regulations and not an appeal right. Therefore requests for adjustments to a claim
that result from clerical errors must be handled through the reopening process.


Requests for adjustments to claims resulting from clerical errors must be handled through the
reopening process. Requests must be made within one year from the date on the initial
determination. With good cause, which is determined by CMS, providers may have a four year
timeframe to initiate a reopening after the date of the initial determination.



When a claim is reopened, NHIC manually goes into the original claim and adjusts it. An
example of an appropriate reopening: While reviewing your Remittance Advice, you come
across an incorrect claim. You notice that the code reads 99232 when it should have been billed
as a 99213. This is a billing error. The claim can be reopened and adjusted to reflect the
appropriate procedure code.


Most reopenings can be done over the telephone; some must be requested in writing.

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