September 4, 2007
When to Request a Reopening vs. a Redetermination and the Proper Forms to Use
To ensure that Reopenings and Redetermination requests are submitted properly to Medicare, a basic overview and examples of these requests as well as the proper forms to use is provided below. By filing these requests on the proper forms, this will ensure they are handled in a timely fashion.
Reopenings Request (formerly known as Written Adjustments)
The Reopenings process has been established for the correction of denials with minor errors and omissions that do not necessitate the use of the formal appeals process. A Reopening Request must be made within one year from the date of notice of the initial determination. For situations that fall into the category of a minor error/omission, the provider should request a Reopening. A Reopening must state the reason the inquiry is being sent to the Medicare office and can be submitted (but is not required) on the Reopenings Adjustment form (see link below). Below are some examples of requests that may be resubmitted as Reopenings:
- To correct a claim for clerical errors or omissions (i.e. add modifier, correct date of service, correct number of service, place of service, submitted amount, CPT code, etc.)
- If benefits are exhausted by primary insurance company
- If Medicare is secondary and we originally denied claim for missing EOB and provider is sending EOB from primary insurance
- Timely filing denials
Reopenings
Adjustment Request Form
Helpful Hints: Please do not use the Written Adjustment Request form for claims that denied as unprocessable with MOA code MS130 and/or Reason Code CO-16 on the Medicare remittance advice. A new claim will need to be submitted with all necessary information. Also ensure that all the information provided on the form is legible.
Please mail your Reopenings request to the following PO Boxes:
Idaho
CIGNA Government Services
Attn: Reopenings
PO Box 22599
Nashville, TN 37202
Tennessee
CIGNA Government Services
Attn: Reopenings
PO Box 1465
Nashville, TN 37202
North Carolina
CIGNA Government Services
Attn: Reopenings
PO Box 671
Nashville, TN 37202
Redeterminations Request (formerly known as Appeals)
The Redetermination is the first level of appeal. Medicare regulation states that a party who is dissatisfied with an initial determination may request the carrier review such determination. A Redetermination must state the reason a review is being requested, include documentation that warrants a review of the initial decision and can be submitted (but is not required) on the Redetermination 20027 form (see link below). Redetermination requests must be submitted within 120 days from the initial claim determination. If a request is received after 120 days and good cause can be found for late filing, that reason needs to be indicated in line 6 of the Redeterminations Request form. Below are some examples of requests that may be submitted as a Redetermination:
- Modifier is being added to support a global denial. Note: If adding modifiers 25, 24, 58, 78 or 79, please include comments supporting the reason for adding these modifiers.
- Claim denied for a duplicate service. Note: Documentation should be included to support each service billed.
- Ambulance denials. Note: Run tickets should be included to support each trip.
- Charges denied as Part A because the patient was seen in the office prior to admission in the hospital. Note: Documentation should be included to support the office service.
- Claim denied as not medically necessary and a GA modifier has been added to the claim. Note: A copy of the Advance Beneficiary Notice should be included with the request.
Helpful Hints: In order to process your request timely and accurately, it is very important that all required elements (lines 1 – 4, 8, 10 & 12 of the request form), all notes and supporting documentation are included with the request. Also ensure that all the information provided on the form is legible.
Please mail your Redeterminations request to the following PO Boxes:
Idaho
CIGNA Government Services
Attn: Redeterminations
PO Box 22990
Nashville, TN 37202
Tennessee
CIGNA Government Services
Attn: Redeterminations
PO Box 23950
Nashville, TN 37202
North Carolina
CIGNA Government Services
Attn: Redeterminations
PO Box 24770
Nashville, TN 37202
