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Last Modified: 2/6/2021 Location: FL, PR, USVI Business: Part B

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 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 in the gateway

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
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.