Last Modified: 8/1/2020
Location: FL, PR, USVI
Business: Part A
Part A providers must 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
There are two options you must use to request a reopening:
• Type of bill (TOB) XXQ
• Must include UB-04 claim form with documentation to support an override exception
Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of First Coast. When a claim correction is discovered and the claim is beyond the timely filing limit (one calendar year from the "through" date on the claim), a reopening request (TOB XXQ) can be submitted. If a claim needs correcting and the claim is within the timely filing limit, an adjustment (TOB XX7) can be submitted.
• 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 return to provider (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 will 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.
The customer service telephone claim override timeliness process has expired. Part A providers are required to follow the coding and billing guidelines outlined in SE1426, which adheres to the exceptions
established by the Centers for Medicare & Medicaid Services (CMS) to request an extension of time limit provision.
The exceptions are explained below.
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.