Proper Submission of Reopening Requests

National Government Services has identified an issue where providers are submitting reopening requests to change or add diagnosis codes on paid claims. These reopening requests do not impact the outcome of the claim; therefore, they are dismissed. This practice increases workloads and decreases operational efficiency. Please adhere to the following guidelines to ensure proper claim submission and processing.

Clerical Error Reopening Requests

A reopening is a remedial action taken to correct a decision that resulted in an overpayment or underpayment. This action is applicable when the original decision was incorrect based on the evidence of record.

Please note that clerical errors do not encompass omissions or the failure to bill for certain items or services.

Changing/Adding Diagnosis Codes on Paid Claims

Submitting a reopening request solely to change or add a diagnosis code on a fully adjudicated and paid claim does not qualify as a clerical error reopening. Such requests are dismissed without correction. They do not change the outcome of the claim but are often used improperly.

Correct Action: If the diagnosis code change is necessary to support the medical necessity of the services/items/procedures provided, you must file a redetermination with supporting medical documentation within 120 days of the claim's finalization.

Understanding Denied Versus Rejected/Returned to Provider Claims

• Denied Claims: These are fully adjudicated, and you may appeal the decision. Correct errors through an appeal with supporting documentation, or a reopening when applicable.
• Rejected and RTP Claims: These are not fully adjudicated and are not eligible for appeal. Use a new claim submission to correct errors.

Related Content and Reminders

• Review the Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10, for detailed reopening guidelines.
• Ensure that all claims are submitted accurately and completely to avoid unnecessary delays. View our job aid How to Avoid Costly Appeals for assistance.
• Utilize our job aid regarding Reopening versus Redetermination to distinguish between what is allowed as a clerical error reopening and what must be submitted as a redetermination.
• About Appeals
• Reopening Request Timeframes
• Levels of Appeals & Time Limits for Filing 
• Reopenings for Minor Errors and Omissions

Please ensure you share this information with your team members that are responsible for submitting claims, appeals and any inquires to NGS so we can work together to streamline and improve these inefficiencies.

Posted 1/2/2025