Automation of the request for reopening claims process

This article informs you and your vendors about changes that will allow you to request reopening of claims electronically. To request a reopening, you will report a new type of bill (TOB), XXQ, along with condition codes to indicate that the claim is a request for reopening.

Effective on or after January 1, 2016, all providers must use the new reopening process, TOB XXQ, 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).

The CMS issued change request CR8581 to assist with billing the TOB XXQ and the reopening adjustment reason code.

Reopenings are different from adjustment bills. Adjustment bills are subject to normal claims processing timely filing requirements (filed within one year of the date of service). Reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed. They are allowed only after the normal claims timely filing period has expired and they are separate and distinct from the appeals process. A reopening will not be granted if an appeal decision is pending or in process.

You may not request a reopening on fully denied claims, or line items denied through medical review. You must appeal these types of claims.

When submitting the Medicare Part A Redetermination and Clerical Error Reopening Form do not use new coding created for TOB XXQ. Inaccurate reporting of coding specific to TOB XXQ may result in returned claims.

Electronic or direct data entry

Electronic or direct data entry (DDE) claims for reopening requests must include the following:

• TOB:
  • XXQ
• Reopening condition code:
  • R1 – Mathematical or computational mistake
  • R2 – Inaccurate data entry
  • R3 – Misapplication of a fee schedule
  • R4 – Computer errors
  • R5 – Incorrectly identified duplicate
  • R6 – Other clerical error or minor error or omission
• Failure to bill for services is NOT considered a minor error
  • R7 – Correction other than clerical error
  • R8 – New and material evidence is available
  • R9 – Faulty evidence
• Condition code to identify what was changed:
  • D0 – Changes in service date
  • D1 – Changes to charges
  • D2 – Change in revenue code / HCPCS / HIPPS rate codes
  • D4 – Change in clinical codes for diagnosis and/or procedure codes
  • D9 – Change in condition codes, occurrence codes, occurrence span codes, provider ID, modifiers and other changes
  • E0 – Change in patient status
• Condition code W2 - Attesting that this is a rebilling and no appeal is in process

Note: You cannot request a reopening and an appeal on the same claim simultaneously.

DDE claims only

Report a reopening ‘adjustment reason code’ on claim page three (MAP1713):

• R1 – less than one year from initial determination date:
  • Remarks not required, but may be added to provide additional information for claims processing
• R2 – one to four years from initial determination date:
  • Remarks are required
• R3 – more than four years from initial determination date:
  • Remarks are required

Reopenings that require 'good cause'

Reopenings that require "good cause" must have remarks on claim page four (MAP1714). "Good cause" remarks must be the first remarks on the claim and must be formatted as shown below without the parenthetical explanation; failure to follow the required formatting will result in your claim returning to provider (RTP) for reason code 39995.

• Good Cause– C-A CC (Changed or added condition code) because…
• Good Cause– C-A OC (Changed or added occurrence code) because…
• Good Cause– C-A OSC (Changed or added occurrence span code) because…
• Good Cause– C-A VC (Changed or added value code) because…
• Good Cause– C-A DX (Changed or added diagnosis code) because…
• Good Cause– C-A MOD (Changed or added Modifier) because…
• Good Cause– C-A PX (Changed or added procedure code) because…
• Good Cause– C-A LIDOS (Changed or added line item date of service) because…
• Good Cause– C-A PSC (Changed or added patient status code) because…
• Good Cause– C-A HCPCS (Changed or added HCPCS code) because…
• Good Cause– C-A HIPPS (Changed or added Health Insurance Prospective Payment System Code) because…
• Good Cause– NME (New and Material Evidence) because…
• Good Cause– F-E (Faulty Evidence) because…

Any reopening request that contains changes or additions from the original claim should contain remarks explaining what was changed or added. If the change or addition affects a line item(s), include the affected line(s) in remarks.

If the reopening is less than one year from the claim processed date, no specific remarks are required.

Example

A claim for dates of service January 5, 2015, is processed on March 17, 2015. You can submit an XXQ claim on or after January 5, 2016, with no specific remarks until March 17, 2016.

Any XXQ claims received after March 17, 2016, must include specific remarks as outlined above under "good cause."

Scenarios not accepted as a reopening

The following scenarios, submitted after the claim submission timely filing (one year from the date of service) has expired, will not be accepted as a reopening request and will RTP with reason code 39997 (Effective October 1, 2015: a request for reopening claim, type of bill frequency code equal to q, has been received. The Medicare contractor does not allow this reopening request.)

• Additional charges or services not previously billed per the CMS IOM Pub. 100-04 Medicare Claims Processing Manual Publication, Chapter 34, section 10.4
• When another insurance recoups their payment, per CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 34, section 10 

Note: Adjustments / reopening for higher weighted DRGs must be filed within 60 days from the initial claim determination.

For more information on the reopening process, please review the following article:

• CR8581 - Automation of the request for reopening claims process