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CMW Tip of the week: Understand the difference between a Medicare appeal and a Medicare reopening

Case Management Weekly, November 19, 2008

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This week’s tip is provided by Deborah K. Hale, CCS.

When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.

If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.

Valid reopening errors include:

• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer error
• Denial of claims as duplicates, which the party believes were incorrectly identified as a duplicate
• Incorrect data items, such as provider number, use of a modifier, or date of service

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

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