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Last Modified: 6/21/2018 Location: FL, PR, USVI Business: Part B, Part A

Claim reopening: Request types FAQ

Q: What types of changes may I include in a claim reopening request? May I change more than one field on each line item? Can I add or remove line items?
A: Part A providers may use SPOT to submit a request for clerical corrections to eligible line items in your Part A claim. Providers must submit any accompanying documentation along with the CMS-1450 (UB-04) form pdf file.
Part B providers may conduct a clerical claim reopening through the SPOT with the ability to make corrections to the following fields:
Date of Service (DOS)
Diagnosis Code (primary)
Procedure Code
Modifier
Units Billed
Only one claim reopening request type may be selected for each eligible line item, and the type of request is determined by the primary field to be corrected.
Some types of requests may allow the editing of more than one field (i.e., primary and secondary fields). However, the primary field is based upon the request type selected, and the primary field is always a required field.
Some modifiers and procedure codes are ineligible for clerical claim reopening through SPOT.
select request type

Claim Reopening: Request types and tips

Claim reopening request type
Primary field(s) (Required)
Secondary field (Optional)
Comments
Edit DOS From
DOS From
N/A
DOS From date may not be later than DOS To date.
Edit DOS To
DOS To
N/A
DOS To date may not be earlier than DOS From date
Edit DOS Both
DOS From
and DOS To
N/A
Both DOS fields must be changed
Edit diagnosis Code
Diagnosis code
N/A
The primary diagnosis code may be changed.
Edit procedure code
Procedure code
Billed amount
The replacement code must be one that may be used in a claim reopening request.
Add modifier
Modifier
(first available field)
N/A
Only one modifier may be added, and it must be one that may be used for a reopening request.
Edit modifier
Modifier
(any modifier field that contains a value)
N/A
Only one modifier may be replaced, and it must be one that may be used for a reopening request.
Delete modifier
Modifier
(any modifier field that contains a value)
N/A
Only one modifier may be deleted.
Edit units billed
Units billed
DOS From, DOS To, Billed Amount
Anesthesia providers must use units and not minutes when adjusting units billed. The conversion factor is 1 unit = 15 minutes. For example, 75 minutes would be entered as 5 units (75/15=5 units).

Limitations to claim reopenings on the SPOT

Multiple request types (e.g., Edit Procedure Code and Add Modifier) may not be utilized for the same eligible line item
Line items may not be added or removed
History corrections (e.g., updates to beneficiary information or status) may not be submitted
Rendering provider’s NPI may not be changed
Claim reopening requests submitted through the SPOT must be filed within one year of the receipt of the initial determination
Multiple modifiers, procedure codes, or diagnosis codes may not be added through the SPOT
Claim reopening requests without any changes may not be submitted through the SPOT
For step by step instructions, please refer to The SPOT: User Guide pdf file
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