Q&A: Differentiating between a claim appeal and reopening of a claim

Q: What is the difference between a Medicare claim appeal (redeterminiation) versus reopening of a claim?

A: Appealing a claim is treated differently than reopening a claim. As part of its claim review process, Medicare may request the patient’s medical records before paying the claim. Medicare will suspend the claim for no more than 45 days to give the hospital the opportunity to submit the requested medical records. Failure to submit the medical record to Medicare will result in the denial of the claim as notmedically necessary based on a lack of documentation. Should the hospital appeal such a denial, the Medicare medical review department will perform a reopening of the claim instead of an appeal, if all the following conditions are met:

• The hospital failed to submit the requested documentation within 45 days
• The claim was denied because the requested documentation was not received in a timely manner
• The requested documentation is received after 45 days with or without a request for redetermination or reopening
• The request is filed within 120 days of the date of receipt of the initial determination

If the criteria above are not met and the request is for a redetermination submitted within 120 days of receipt of the initial determination, Medicare will handle the claim as an appeal instead of a reopening.

For more information, see The Contemporary Guide to Patient Financial Services.