Reopening versus Redetermination

Reopening versus Redetermination
Reopening
Telephone Reopening Unit
Redeterminations

Reopening versus Redetermination

Understanding your next steps are very important for quick reimbursement and providers are required to know the difference between a reopening or a redetermination.

A reopening is a reprocessing of a claim to fix minor mistakes.
A redetermination is an examination of a claim that includes analysis of documentation.

Providers are encouraged to register for NGSConnex. Providers who are registered to use NGSConnex, should use this option to submit reopening requests electronically.

This guide distinguishes the differences between a reopening and redetermination. Please review and share this information with anyone in your organization who can benefit from this guide.

Reopening (Clerical Error)	Redetermination (Appeal – First level)
To correct a claim(s) determination resulting from minor errors, you should use the reopening process. Mathematical or computational mistake Transposed procedure or diagnostic codes Inaccurate data entry Computer errors Incorrect data items	For partially paid or denied claim(s) resulting from more complex issues that require analysis of documentation. Coverage of furnished items and service Medical necessity claim denials Determination on limitation of liability provision Overpayment determinations
Note: Documentation cannot be submitted with the reopening request when using NGSConnex.	Note: Documentation shall be submitted with the redetermination request when using NGSConnex.

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Reopening

NGSConnex or Part B Reopening Request Form

If the situation meets the criteria for a CER, submit a reopening rather than an appeal (redetermination). Reopening is the quickest route to correct a claim that contained errors.

When there are no changes to the claim; however, the claim needs to be reprocessed with statistical data or information, these claims cannot be reopened in the NGSConnex portal; therefore, initiate via the Part B Reopening Request Form. Please refer to the chart below for additional guidance.

Providers who are registered to use NGSConnex, should use this option to submit reopening requests electronically.

Submitting Part B Reopening Request Form

When submitting a request for correction of 25 or more for the same or similar situation, please complete a Part B Reopening Request Form and attach the Large Various Adjustment Macro (LVAM) form. This form will help to ensure that the correct claims are identified for the adjustments being requested. This also prevents us from having to contact your office for further clarifications.

Examples of like services that can be corrected through our LVAM process are:

Changing modifiers or procedure codes
Adding diagnosis codes
Increasing billed amount
Changing the place of service
Changing the quantity billed

Download and complete the Part B Reopening Request Form

Complete the form by typing the appropriate information.
- If you cannot type the request, please make sure your handwriting is legible.
Complete all areas of the form.
- An incomplete form will not be accepted and your request will be dismissed.
Print the completed form and sign it.
Attach Large Various Adjustment Macro (LVAM) for 25 or more for the same or similar situation
Send to the appropriate NGS mailing address for your jurisdiction, listed on the form.

Large Various Adjustment Macro (LVAM)

The Large Various Adjustment Macro (LVAM) form is an excel spreadsheet and shall be typed entirely to include an internal claim number (ICN).

If you cannot type the request, please make sure your handwriting is legible.
Any incomplete LVAM request may be sent back to the provider as an incomplete submission.

The Large Various Adjustment Macro (LVAM) form includes:

Patient’s name
Patient’s HIC/MBI
Date of service
ICN
Procedure code
Explain correction needed

Examples of like services that can be corrected through our LVAM process are:

Changing modifiers
Procedure codes
Adding diagnosis codes
Increasing billed amount
Changing the quantity billed

Situation	Helpful Tips
Modifiers 24 and 25	Appropriate for E/M and eye exam codes (99 series and codes 92002, 92004, 92012, 92014).
Modifier 26	Appropriate for radiology codes (70000–79999), lab (80000–89999).
Modifier 33	Appropriate to identify preventive services when the primary purpose of the service is the delivery of an evidence-based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory).
Modifier 50	To identify procedures done bilaterally. Could be a correction for a claim that was billed with two UOS instead of being billed with one UOS and a 50 modifier.
Modifier 57	Appropriate for E/M and eye exam codes (99 series and codes 92002, 92004, 92012, 92014).
Modifier 58	Appropriate for surgery codes (10000–69999), but not for surgery codes that have a “0” day global period. View the Fee Schedule Lookup tool. The “Details” screen will show the MPFS data base policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifiers 59 (XE, XP, XS or XU)	Appropriate for distinct procedural services. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day to the same patient. Not appropriate with E/M codes.
Modifier 78	Appropriate for surgery codes (10000–69999), but not for some surgery codes that have a “0” day global period. View the Fee Schedule Lookup tool. The “Details” screen will show the MPFS data base policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifier 79	Appropriate for surgery codes (10000–69999).
Modifier 90	Only independent billing clinical laboratories (specialty 69) can bill with the 90 modifier. Line item 20 or electronic equivalent shall be checked “yes,” list purchase price, and complete item 32 with NPI, name and address where test was performed.
Modifier AT	Appropriate for procedure codes 98940, 98941 and 98942.
Modifiers: FX and FY	FX is appropriate to use when x-ray is taken by film. FY is appropriate when ray taken using computed radiography technology/cassette-based imaging.
Modifiers GV and GW	GV appropriate when attending physician is not employed or paid under agreement by the patient’s hospice provider. GW appropriate when service not related to the hospice patient’s terminal condition.
Modifier KX	KX appropriate when patient qualifies above the threshold under the exception regulations. These should not be routine reopenings. Providers are required to precalculate up to the therapy caps and submit initial claims with the KX modifier. If there are gender/procedure or gender/diagnosis conflicts, the KX modifier is appropriate to identify services that are gender specific (i.e., services that are considered female or male only), services for transgender, ambiguous genitalia and hermaphrodite. Beginning 1/1/2024, providers shall include the KX modifier on the claim to indicate they believe the dental service is medically necessary and the provider included appropriate documentation in the medical record to support/justify the medical necessity of the service(s). Please note: the KX modifier cannot be added via a reopening, or telephone reopening. These shall be submitted as appeals (redeterminations) with documentation to support the medical necessity.
Modifier PT	Appropriate to report a diagnostic procedure that began as a screening colonoscopy or screening sigmoidoscopy.
Modifier QW	Appropriate for lab codes (80000–89999) that are CLIA (clinical lab improvement amendment) waived test.
Modifier TC	Appropriate only for radiology (70000–79999) and lab codes (80000–89999).
Changing procedure code(s)	To correct a code that either underpaid or overpaid. Ensure that the billed amount reflects appropriate amounts for the changed procedure code(s).
Date of service changes	Month and day changes only. Cannot add another date of service to a claim; this constitutes a new claim.
Diagnosis codes	To correct a claim that denied for diagnosis code(s), because procedure not covered with submitted diagnosis code(s). When you need to add/correct a diagnosis on a paid claim, this does not qualify for a reopening. Make a notation in the medical record of the correction/addition to ensure it is part of the record. The claim will not be corrected, therefore, a new remittance advice will not be issued.
Place of service	To correct a claim that treatment was deemed by the payer to have been rendered in an inappropriate facility. If payment is affected, the ZIP Code will also need to be changed.
Rendering provider	To correct a claim, because claim was submitted with an incorrect rendering NPI.
Units of service	To correct a claim because the information submitted did not support this many services. Anesthesia claims shall be reported in minutes.
Billed in error	Do not resubmit claims. The intent of BIE is to report an overpayment.

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Telephone Reopening Unit

Refer to the chart below for the only scenarios that cannot be initiated in NGSConnex, but can be completed via the Telephone Reopening Unit (TRU) or Part B Reopening Request Form.

Situation	Helpful Tips
Assignment of claims Contractor error only	Assignment: certain claims and certain providers are required by law to accept the Medicare-approved amount as full payment for covered services.
CLIA certifications denials	CLIA certification numbers are ten-digit, issued by state agencies and used on claim submissions. Does not include QW modifier additions.
Duplicate claim denial	TRU will only reopen duplicate denials when a modifier is not required for two exact services that were submitted for the same services.
Updated fee schedule allowance	To view fee schedule amounts, use the Fee Schedule Lookup tool.
Medicare Advantage – beneficiaries in a clinical trial or hospice related only	Beneficiaries may select Medicare Advantage Plan instead of traditional Medicare. These plans are also referred to as Medicare Part C.
MSP – Medicare, now primary	Always check the beneficiary’s eligibility via NGSConnex. Medicare Secondary Payer claims can only be processed within one year from the date of denial or payment. If Medicaid or another government entity paid in error, please submit a written request.
Patient paid amount Contractor error only	To view specific claim submission instructions, please refer to the CMS-1500 Claim Form Completion Instructions , line item 29 or the electronic equivalent.

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Redeterminations

NGSConnex or Part B Redetermination Request Form

A redetermination must be submitted within 120 days from the claim determination or 120 days from the date of the demand letter.

If you disagree with a coverage or payment decision on an initial claim determination and your scenario is not listed in the reopening section above, a redetermination may be requested. Your redetermination request shall include documentation for NGS to review. The quickest route is to appeal via NGSConnex and upload documentation to substantiate the services.

You are encouraged to register for NGSConnex and then should use NGSConnex to submit redetermination requests electronically.

Refer to the following table for applicable tips to help with your redetermination submission.

Situation	Helpful Tips
Timeframe/Documentation	A redetermination must be submitted within 120 days from the claim determination. A redetermination must be submitted within 120 days from the date of the demand letter. Include office records, test results, operative notes and hospital records to substantiate any extenuating circumstance.
Modifier AS	AS is appropriate to indicate a nonphysician practitioner (PA, NP or CNS) served as the assistant at surgery.
Modifiers 80, 81 and 82	80, 81 or 82 appropriate to indicate assistant-at-surgery services are provided by a physician. Check to see if assistant at surgery is allowed on the Fee Schedule Lookup tool. “Details” will show the MPFS database policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifier AQ	Appropriate when services provided in ZIP Code area that does not fall entirely within a designated full county HPSA bonus area.
Modifier CT	Commonly used with CPT codes 70450–70498 71250–71275 72125–72133 72191–72194 73200–73206 73700–73706 74150–74178 74261–74263 75571–75574 Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard, will result in reduction in payment and CT modifier shall be used.
Modifiers GA, GY, GZ	Requests to add the GA, GY or GZ modifier requires a copy of the ABN; therefore, please upload ABN.
Modifier 22	Surgeries for which services performed are significantly greater than usual. You are required to provide a concise statement to support the modifier 22 on the service.
Modifier 23	Appropriate when no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia.
Modifier 51	Providers do not report modifier 51. When multiple surgical procedures performed the same session, to the same beneficiary, by the same provider, multiple surgery guidelines apply and NGS will apply appropriately to surgery codes. Not appropriate for E/M codes. Check to see if multiple surgery rules apply on the Fee Schedule Lookup tool. “Details” will show the MPFS data base policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifier 52	Appropriate to indicate that a service was partially reduced or eliminated at a physician’s discretion.
Modifier 53	Appropriate with medical diagnostic and surgical codes when the procedure is discontinued because of extenuating circumstances. This modifier is used to report the procedure is discontinued after anesthesia is administered to the patient. Commonly billed with codes 44388, 45378, G0105 and G0121.
Modifiers 54 and 55	Modifier 54 for surgery only and appropriate when surgical procedure and another physician provides preoperative and/or postoperative management. Modifier 55 for postoperative management only and appropriate to indicate postoperative management.
Modifier 62	Modifier 62 is appropriate when two surgeons work together as primary surgeons performing distinct part(s) of a procedure. Each surgeon should report their distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes(s). Check to see if co-surgery is allowed on the Fee Schedule Lookup tool. “Details” will show the MPFS data base policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifier 66	Modifier 66 is appropriate when highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the surgical team concept. Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure code. Check to see if team surgery is allowed on the Fee Schedule Lookup tool. “Details” will show the MPFS data base policy indicators. The descriptor of the indicators can be found on the Fee Schedule Assistance page.
Modifier 76	Modifier 76 is appropriate to identify repeat procedure or service by the same provider. If the quantity billed is over the MUE, documentation must be provided. Refer to the CMS Medically Unlikely Edits web page for additional information.
Modifier 77	Modifier 77 is appropriate to identify repeat procedure by a different provider. If the quantity billed is over the MUE, documentation must be provided. Refer to the CMS Medically Unlikely Edits web page for additional information.
Modifier 91	Modifier 91 is appropriate with laboratory codes to report repeat of the same laboratory test on the same day to obtain subsequent (multiple) test results. If the quantity billed is over the MUE, documentation must be provided. Please refer to the CMS Medically Unlikely Edits web page for additional information.
Ambulance Modifiers	Ambulance claims may be complex and suppliers may need to provide separate run times and trip records; therefore, initiate a redetermination and upload documentation to support medical necessity.
Anesthesia Modifiers	Anesthesia claims may be complex and providers may also need to provide separate surgery times; therefore, initiate a redetermination. Documentation may include preanesthesia record, anesthesia record, operative report, radiology report and reason for which anesthesia was rendered for a radiology service.
Changing procedure code to a new patient care code	A “new patient” means a patient who has not received any professional services from the physician or physician group practice (same physician specialty) within the previous three years. Before initiating an appeal, please refer to the Definition of New Patient for Billing Evaluation and Management Services article on our website.
Cosmetic surgery	Be sure to upload documentation to support services. Documentation of medical necessity, operative report, admission summary, history and physical.
Disputing an overpayment	Contractor-initiated overpayments require review of additional documentation; therefore, always initiate a redetermination.
Processed based on multiple or concurrent procedure rules	Be sure to upload documentation to support services. Records for entire hospital course including admission summary, progress notes and order sheets.
Unlisted or NOC codes	Since NOC procedure codes are used to describe many different procedures, Medicare allowable amounts are not established and allowance is based on the supporting documentation. Be sure to upload documentation to support services.

Revised 11/8/2024

Reopening versus Redetermination

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