Reopening versus Redetermination
Table of contents
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.
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For partially paid or denied claim(s) resulting from more complex issues that require analysis of documentation.
|
| Note: Documentation cannot be submitted with the reopening request when using NGSConnex. | Note: Documentation shall be submitted with the redetermination request when using NGSConnex. |
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. |
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. |
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
|
| 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