Last Modified: 4/18/2020
Location: FL, PR, USVI
Business: Part A
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.
• Click here
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 days requirement.
Skilled nursing facility (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.
• Medicare administrator contractors (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 (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.
• Click here
to review 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.
• Click here
if you disagree with the denial reason and would like to request an appeal.
• 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 internet-only manuals (IOM), publication 100-04, Chapter 1
, section 130;
, sections 10.4 and 10.6.2;
publication 100-05, Chapter 5
, section 22.214.171.124.1
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