Medicare streamlines process for reopening claims

By Judith Kares

This week we will continue our discussion on several Medicare processes involving changes to claims as originally submitted and/or adjudicated. We will review the five-level Medicare appeals process (Appeals Process) and the relationship of that process to claim adjustments (Adjustments) and reopenings (Reopenings). 

Overview of prior discussion on Adjustments and Reopenings

In my note on January 14, we focused on timely claim Adjustments and the Reopening of claims. Before we explore the Medicare Appeals Process, let’s summarize our prior discussion. When a provider needs to correct or supplement a claim, the provider generally may correct the error or omission by submitting an Adjustment claim, so long as the submission is within the timely filing limits for those items or services (generally one year from the date of service). When the need for a correction is discovered beyond the timely filing limits, however, an Adjustment bill is not allowed. A provider must utilize the Reopening process to correct the error or omission. (See Medicare Claims Processing Manual (MCPM), Chapter 1, Section 70.5, for more information on Adjustments.)

For Medicare purposes, “a reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record”. Traditionally, CMS has permitted A/B Medicare Administrative Contractors (A/BMACs) to develop their own reopening processes, potentially subjecting providers to different processes in different jurisdictions. Effective January 1, Medicare implemented a new streamlined, standardized process for providers to request the Reopening of a claim. In three releases--Medicare Claims Processing Transmittal R3219CP and related MLN Matters articles MM8581, and SE1426—CMS set out the details for this new process. (See MCPM, Chapter 34, for more information on Reopenings.)

Medicare Appeals Process

Once certain decisions or determinations have been made by a contractor (A/BMAC, Recovery Auditor, etc.) or an adjudicator (Qualified Independent Contractor [QIC], ALJ or Appeals Council [AC]), a party (beneficiary, provider, supplier) to that decision has certain appeal rights under the Medicare Appeals Process. The current Medicare Appeals Process, which has been in effect for a number of years, has five levels of appeal:

• First level—A/BMAC Redetermination
• Second level—QIC Reconsideration
• Third level—ALJ Hearing
• Fourth level—Appeals Council Review
• Fifth level—Judicial Review

We will explore each level of review in more detail in this week's Note from the Instructor.