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May 2, 2008

Reopenings Timely Filing Information

When a Reopening request is received for a service that the initial denial was based on timely filing or the provider is requesting that we reopen and revise our initial determination, the following guidelines will apply:

• The provider may request the contractor reopen and revise its initial determination within 1 year from the date of the initial determination for any reason.
• Within 4 years from the date of initial determination for good cause.
• At anytime if the initial determination is unfavorable, but only for the purpose of correcting a clerical error on which the determination was based.

  Clerical errors include:

  • Mathematical or computational mistakes
  • Transposed procedure or diagnosis codes
  • Inaccurate data entry
  • Misapplication of a fee schedule
  • Computer errors
  • Duplicate claim denials believed to be erroneous
  • Incorrect data items (PIN/NPI, use of a modifier, DOS, etc.)

  Note: This does not include failure to bill for certain items or services.

Good cause is defined as:

• New and material evidence that was not available or known at the time of the determination or decision and may result in a different conclusion.

• New and material evidence includes any evidence which was not considered when the previous determination or decision was made and which shows facts not available and that may result in a conclusion different from that reached in the determination or decision. Thus, the submittal of any additional evidence is not a basis for reopening. The information must be “new” (i.e. not readily available or known to exist at the time of the initial determination).

• Third party payer error does not constitute new and material evidence nor does it constitute good cause. Contractors may only reopen for third party payer error under the “within one year for any reason” standard. All providers, physicians, and other suppliers have a legal obligation to determine the correct primary payer when billing Medicare. Failure to do so, regardless of third party payer error, does not constitute good cause. Information regarding such error does not constitute “new and material evidence”.

• Medicare does not consider a situation where Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare system of records and a third party mistakenly paying primary when it alleges that Medicare should be primary to constitute good cause to reopen.

• The evidence that was considered in making the determination or decision clearly shows that an obvious error was made at the time of the determination or decision (i.e. administrative error, etc.)

The above information was extracted from CMS’s website and on occasion these guidelines can change. Therefore, please refer to the below link (Chapter 34, section 10.4, 10.6.2, 10.11, & 10.11.1) to get the most up to date information regarding Reopenings request.

http://www.cms.hhs.gov/manuals/downloads/clm104c34.pdf 

Initial Claims Filing Guidelines

Claims must be filed to Medicare on or before December 31 st of the calendar year following the year in which the services were furnished. Services furnished in the last quarter of the year are considered furnished in the following year.

The table that follows illustrates the timely filing limit for dates of service in each calendar month.

The above information was extracted from CMS’s website. Please refer to the below link (Chapter 1, section 70 & 70.1) for additional information regarding initial claims filing guidelines.

http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf