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Last Modified: 10/13/2019 Location: FL, PR, USVI Business: Part A

Claim reopening vs adjustment FAQ

Q: What is the difference between a claim reopening and an adjustment?
A: Reopenings are different from adjustment bills based on the following rules:
Adjustment bills are subject to normal claims processing timely filing requirements (that is, 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 (for example, claim determinations may be reopened within one year of the date of receipt of the initial determination, or within one to four years of the date of receipt of the initial determination upon a showing of good cause). Reopenings are only allowed after the normal timely filing period has expired.
Providers that need to correct or supplement information on paid (status/location P/B9997) and/or rejected (status/location R/B9997) claims may refer to the following:
Claim adjustment guidelines
Providers may submit adjustment claims (type of bill (TOB) xx7) to correct errors or supplement a claim when the claim remains within the timely filing limits.
Click here for additional information on the timely filing guidelines.
Click here to review the claim data elements required for adjusting and/or canceling claims.
Examples of timeliness for filing claim adjustments:
Timely filing period – Use TOB xx7

Claim “through” date
Remittance advice date
Adjustment period (based on “through” date)
10/01/18
11/01/18
11/02/18 – 09/30/19
10/01/18
03/31/19
04/01/19– 09/30/19
10/01/18
09/30/19
N/A – timely filing period has elapsed
Claim reopening guidelines
Providers billing electronic media (EMC) or direct data entry (DDE) claims must utilize the new reopening process (TOB xxQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill is not allowed.
Do not submit hard copy claims (via CMS-1450 form [UB-04]) with TOB xxQ.
Click here to learn about the process changes for Part A claims reopening beyond the timely filing limit.
Examples of timelines for filing claim reopenings:
Beyond timely filing period – Use TOB xxQ

Claim “through” date
Remittance advice date
Reopening period – ARC=R1 (based on RA date)
Reopening period – ARC=R2 (based on RA date)
Reopening period – ARC=R3 (based on RA date)
10/01/18
11/01/18
10/01/19 - 10/31/19
11/01/19 - 10/31/22
11/01/22 and beyond
10/01/18
03/31/19
10/01/19 – 03/30/20
03/31/20 – 03/30/23
03/31/23 and beyond
10/01/18
09/30/19
10/01/19 – 09/30/20
10/01/20 – 09/29/23
09/30/23 and beyond
Source: CMS internet-only manuals (IOM), publication 100-04, Chapter 1 external pdf file, section 130;
Chapter 34
external pdf file, sections 10.4 and 10.6.2;
publication 100-05, Chapter 5 external pdf file, section 60.1.3.2.1
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.