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Last Modified: 10/7/2021 Location: FL, PR, USVI Business: Part A

Part A claim reopenings beyond timely filing limit process changes

Part A providers may request First Coast to reopen a claim when:
You want a clerical reopening to correct minor errors or omissions, but the date of service is beyond the timely filing provision
Your claim rejected with reason code 39011 because the through date of service is past the 12-month timely filing provision
To request a reopening, you must report a new type of bill (TOB), XXQ, along with condition codes to indicate that the claim is a request for reopening. All providers must use this TOB XXQ reopening process when a correction is to be made beyond the timely filing limit (one year from the through date of the service). An adjustment TOB XX7 is not allowed and the claim will return to provider (RTP).
If you submit a reopening by mail or through secure messaging in SPOT using our Request for a Redetermination/Reopening of a Part A Medicare claim pdf file form, do not use new coding created for TOB XXQ. Inaccurate reporting of coding specific to TOB XXQ may result in returned claims. You must include the UB-04 claim form with documentation to support an override exception.

Instructions for claim corrections beyond timely filing limit

CMS released MLN Matters article MM8581 external pdf file and special edition (SE) article 1426 external pdf file to assist providers with coding instructions and billing scenarios when submitting requests to reopen claims that are beyond the claim timely filing limit using TOB XXQ. Here are a few reminders from those articles:
An XXQ TOB can only be submitted after the timely filing limit (one calendar year from the “through” date on the claim) and cannot be submitted via hardcopy (paper) UB-04.
Clerical claim requests must be submitted via the 5010 format or directly into the Fiscal Intermediary Standard System (FISS) via direct data entry (DDE).
Reopenings are separate and distinct from the appeals process.
A reopening will not be granted if an appeal has been requested and a decision is pending or in process.
Claims that have been fully denied cannot be reopened. Providers must appeal these claims.
Note: Claim lines denied through Medical Review are not allowed to be reopened; however, claim lines not denied through Medical Review can be reopened. Also, claims with a status of RTP cannot be reopened with the TOB XXQ. For RTP claims, you must submit a new claim and provide remarks on the claim as to why you are billing the claim past the timely filing. We’ll review the information in the remarks and make a determination on the claim. If we reject the claim, then you may request to have the claim reopened.

Claims timely filing exceptions

Part A providers are required to follow the coding and billing guidelines outlined in SE1426, which adheres to the exceptions external pdf file established by CMS to request an extension of time limit provision.
The exceptions are explained below.

Administrative error
Failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).
Retroactive Medicare entitlement
At the time services were furnished, the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).
Retroactive Medicare entitlement involving State Medicaid Agencies
State Medicaid Agency recoups payment six months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished, the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired (See 70.7.3).
Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization
A beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier six months or more after the date the service was furnished (See 70.7.4).
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.