Help for Minor Claim Denials via CMS TRU

Dermatology practices can now use the Centers for Medicare & Medicaid Services (CMS) telephone reopening unit (TRU) to change a claim-denial determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was made correctly based on the claim-documentation evidence available on record.

Dermatology practices may request a reopening of an original claim-processing decision by contacting TRU. TRU representatives will reopen and correct minor and uncomplicated claims due to provider or carrier clerical errors or omissions.

Reopenings are separate and distinct from the appeals process. Reopenings are considered discretionary actions on the part of the Medicare Administrative Contractor (MAC). A contractor’s decision to reopen a claim determination should not be considered an initial determination and is not appealable. Requesting a reopening does not affect the time frame for requesting an appeal. If the reopening action results in a revised determination, then new appeal rights are offered on that revised determination. Under certain circumstances, a party may request a reopening even if an appeal has not expired.

Issues pertaining to limitation of liability, medi-cal necessity denials, and reductions or analysis of documents such as operative reports and clinical summaries cannot be addressed through TRU. CMS considers conducting telephone reopenings inappro-priate in most instances because of their complexity. MACs have the discretion to decide whether to conduct a reopening on the issues listed above.

The following are examples of issues best handled by TRU:

• Adding or changing the provider rendering services

• Adding or changing order of referring/supervising physician

• Assignment of claims (carrier errors only)

• Clinical Laboratory Improvement Amendments (CLIA) certification denials

• Duplicate denials

• Fee schedule errors

• Health insurance claim (HIC)/ Medicare beneficiary identifier (MBI) corrections (carrier error only)

• Medicare Advantage (MA) plan denials (clinical trial- or hospice-related only)

• Modifier GV and GW

• MSP – Medicare now primary

• Patient-paid amount (carrier error only)

• Place of service (POS) changes

For more information on telephone reopenings, visit Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10.11. at https://www.cms.gov/Regula-tions-and-Guidance/Guidance/Manuals/Downloads/clm104c34.pdf.