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Last Modified: 3/23/2018 Location: FL, PR, USVI Business: Part A

Common reason for adjusting and reopening claims FAQ

Q: What are some common situations when I can or cannot adjust or reopen claims?
A: Providers are responsible in determining when it is appropriate to make corrections to paid (status/location P/B9997) or rejected (status/location R/B9997) claims. Listed below are some helpful hints in determining when you can or cannot correct claims:
Clerical or minor claim error corrections
Mathematical or computational mistakes
Transposed providers or diagnostic codes
Inaccurate data entry
Misapplication of fee schedule
Computer errors
Denial of clams as duplicates which the party believes were incorrectly identified as a duplicate
Incorrect data items, such as provider number, use of a modifier or date of service
Tolerance guidelines for adjusting hospitals and skilled nursing facilities (SNF) claims
Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days)
Blood deductible
Change in the Part B cash deductible of more than $1.00
Inpatient hospital cash deductible of more than $1.00
Servicing hospital or SNF provider number
Hospital outlier payment
Discharge status
Adding charges or services
Providers may adjust claims (TOB xx7) to add charges or services when the claim is within the timely filing period.
Providers are not permitted to add charges or services on an initial bill after the expiration of the time limitation for filing a claim.
Click here for additional information on the timely filing guidelines.
Hospital diagnosis related group (DRG) claim adjustments
Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.
Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.
Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments
SNF adjustments to change in HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.
Medically denied claim
It is not appropriate to adjust claims that have medical review (MR) denials (status/location D/B9997), or paid claims with line item(s) denials.
Medicare administrator contractors (MACs) will not allow claim lines that have been denied through a MR process (for example, MR, recovery audit contractor (RAC), comprehensive error rate testing (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.
Click here to review the process on how to determine when a claim was medically reviewed and how to make changes.
Providers must submit appeal request for claim denials based on medical records, including failure to respond to medical record requests.
Click here if you disagree with the denial reason and would like to request an appeal.
Additional reminders
Do not adjust claims in status/location P/B9996 (payment floor) until they have reached final disposition.
Claims in status/location P/B7516 or R/B7516 (Medicare secondary payer post pay) will be held for at least 75 days (CMS cost avoidance savings), and cannot be adjusted until they have reached final disposition.
Third party payer error in making primary payment does not constitute “good cause” for the purpose of reopening a claim beyond one year of the initial determination.
A contractor’s decision to reopen or not reopen a claim, regardless of the reason for the decision, is not subject to an appeal.
A reopening will not be granted if an appeal decision is pending or in process.
Source(s): 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.