Claim reopening: Request types FAQ

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Home ► FAQs ► Answers ► Claim reopening: Request types FAQ

Last Modified: 4/10/2020 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 select their reopening type. The five request types are:

• Entitlement

• Hospice, where modifier GV or GW may be added

• History Correction, where the claim may be submitted without any changes

• MSP (Medicare secondary payer)

• Other Corrections

• Date of Service (DOS)

• Diagnosis Code (primary)

• Procedure Code

• Modifier

• Units Billed

• Billed Amount

In SPOT, go to Appeals, then Reopen a Claim. You will see the Claim Reopening Inquiry form (Part B):

If you select Other Corrections, for example, you will be directed to the Claim Reopening Request form.

• 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.

Claim Reopening: Request types and tips

Claim reopening request type	Primary field(s) (required)	Secondary field (optional)	Comments

Hospice	Add Modifier	N/A	Modifier GV or GW is required
History Correction	N/A	N/A	Submitting with no changes
Eligibility	Beneficiary full name	N/A	Coverage is based on date of service
MSP	Beneficiary full name	N/A	Coverage is based on date of service
To access the following reopenings, select Other Corrections from the drop-down menu
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 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	Optional fields: 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).
Edit Billed Amount	Billed Amount	N/A	Note: An adjusted billed amount that is less than the allowed amount for the service is not accepted as it may result in an overpayment.

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

• Certain 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

For step by step instructions, please refer to The SPOT: User Guide pdf file

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