Reopening Request Timeframes

According to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10.6.2, Timeframes for Party Requested Reopenings:

A party may request a contractor reopen and revise its initial determination or redetermination under the following conditions:

• Within one year from the date of the initial determination or redetermination for any reason; or
• Within four years from the date of the initial determination or redetermination for good cause as defined in Section 10.11; or,
• At any time if the initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based. Third party payer error does not constitute clerical error as defined in Section 10.4.

While a contractor can reopen claims at any time under the limited criterion set forth above to correct an unfavorable determination, CMS does not expect that a contractor would regularly grant these requests. The contractor and the provider/physician/ supplier have a reasonable expectation to administrative finality in the processing of their claims. Additionally, administrative efficiency and the ability of a Medicare contractor to continue vital functions (i.e., process Medicare claims and process appeal requests) require that contractors grant such requests rarely.

For additional information about Medicare claim processing requirements, visit the IOMs.

Reviewed 11/21/2024