Claim Reopenings or Level 1 Appeals for Denied Services

Not every Medicare denial requires a formal appeal. Most Medicare Administrative Contractors (MAC) have developed automated claim “reopenings” to handle these simple corrections. This method significantly reduces the amount of time required to reprocess a denial. It is important that reopenings be submitted on the correct form, which can be identified by consulting your local MAC website. The reopening-request form requires correct information (please do not confuse this form with a Level 1 Appeal Redetermination request). Not all MACs have separate forms, and it is important that one follows outlined policies. A reopening request is appropriate when processed claims are denied for minor errors or omissions. Examples presented by the MACs include:

• Date of service correction (within the same year) that does not result in an overpayment

• Place of service corrections/changes

• Correcting a transposed CPT/HCPCS code

• Correcting the number of services (units)

• Changes or additions to diagnosis codes

• Adding, changing, or removing some modifiers

• Correcting the billed amount

• Correcting a zip code

Do not confuse the re-opening for a Level 1 Redetermination Appeal when a claim is denied or partially denied. Confusing the two will only delay payment on the claim. Some common causes of denials include proof of medical necessity; frequency limitations; corrections that require the review of medical records; services submitted with the incorrect year of service; or any other change that is not a simple correction.

For additional information to help you determine whether to submit a reopening or a redetermination, please contact your local MAC contractor.