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Last Modified: 10/21/2022 Location: FL, PR, USVI Business: Part A

Common reasons for adjusting and reopening claims FAQ

Q: What are some common situations when I can or cannot adjust, or reopen a claim?
A: Providers are responsible for determining when a correction may be made to a paid (status/location P/B9997) or rejected (status/location R/B9997) claim. Please review the following for help with your determination.
Clerical or minor claim error correction
Mathematical or computational mistake
Transposed provider number or diagnostic code
Inaccurate data entry
Misapplication of fee schedule
Computer error
Duplicate claim denial when the party believes the claim was incorrectly identified as a duplicate
Incorrect data item, such as provider number, use of a modifier, or date of service
Tolerance guidelines for adjusting hospitals and skilled nursing facilities (SNF) claim
Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days)
Blood deductible
Change in the Part B cash deductible of more than $1.00
Inpatient hospital cash deductible of more than $1.00
Servicing hospital or SNF provider number
Hospital outlier payment
Discharge status
Adding charge or service
Providers may adjust claims (TOB xx7) to add charges or services when the claim is within the timely filing period.
Providers are not permitted to add charges or services on an initial bill after the expiration of the time limitation for filing a claim.
Review Claims timely filing for additional information on the timely filing guidelines.
Hospital diagnosis related group (DRG) claim adjustment
Hospital adjustments to correct the diagnostic and procedure coding on the claim to a higher weighted DRG must be submitted, within 60 days of the paid remittance.
Claim adjustments that result in a lower weighted DRG are not subject to the 60 day-requirement.
SNF health insurance prospective payment system (HIPPS) code adjustment
SNF adjustments to change HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.
Medically denied claim
It is not appropriate to adjust a claim that has a medical review (MR) denial (status/location D/B9997), or a paid claim with line item(s) denials.
MACs will not allow claim lines that have been denied through a MR process (for example, MR, recovery audit contractor (RAC), Comprehensive Error Rate Testing program (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.
Review Identifying medically reviewed adjudicated claims for the process on how to determine when a claim was medically reviewed, and how to make changes.
Providers must submit an appeal request for a claim denial based on medical records, including failure to respond to a medical records request.
Review Calculate the time limit for filing each level of appeal if you disagree with the denial reason and would like to request an appeal.
Additional reminders
Do not adjust a claim in status/location P/B9996 (payment floor) until the claim has reached final disposition.
Claims in status/location P/B7516 or R/B7516 (Medicare secondary payer post pay) will be held for at least 75 days (CMS cost avoidance savings) and cannot be adjusted until the claim has reached final disposition.
Third party payer error in making primary payment does not constitute “good cause” for the purpose of reopening a claim beyond one year of the initial determination.
A contractor’s decision to reopen or not reopen a claim, regardless of the reason for the decision, is not subject to an appeal.
A reopening will not be granted if an appeal decision is pending or in process.
Source(s): CMS IOM, Pub. 100-04 Claims Processing Manual, Chapter 1 external pdf file, section 130;
Chapter 34
external pdf file, sections 10.4 and 10.6.2;
Pub. 100-05 Medicare Secondary Payer (MSP) Manual, Chapter 5 external pdf file, section
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.