powered by LeadingAge New York
  1. Home
  2. » Providers
  3. » Nursing Homes
  4. » Fall 2016 CFO Council Meetings
  5. » Guidance on Re-opening Medicare Claims

Guidance on Re-opening Medicare Claims

The Centers for Medicare and Medicaid Services (CMS) have issued two important guidance documents on the re-opening of Medicare claims after the initial claims filing deadline has expired.  Providers are reminded of the current timely filing requirements:

For institutional claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim will be used to determine the date of service for claims filing timeliness.

For professional claims (CMS-1500 Form and 837P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date will be used to determine the date of service and filing timeliness. (This includes supplies and rental items).

(For more details, please see Medlearn Matters MLN MM7080.)

When a provider needs to correct or supplement a claim, and the claim remains within the timely filing limits, the provider may submit an adjusted claim to remedy the error. When the need for a correction is discovered that falls beyond the timely filing limit, an adjustment bill is not allowed and the provider must utilize the reopening process.

Re-openings are written requests for corrections that include supporting documentation. Up until recently, however, CMS has not mandated a standard process across all Part A Medicare Administrative Contractors (MACs).  In order to standardize the process for providers to request re-openings, CMS has developed a “new” bill type frequency code to be used by providers indicating a Request for Reopening and a series of Condition Codes that can be utilized to identify the type of Reopening being requested.   

The new standardized process and specific codes to be used to designate a re-opening are now available from MLN MM8581.  Companion information and more technical standards are available in MLN SE1426.  The decision to re-open a claim remains discretionary on the part of the MAC.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827