Case Management

Mentor moment: Reopening or appeal?

Case Management Weekly, August 22, 2012

If your claim includes a minor or clerical error, consider reopening instead of appealing it. 

The basis of reopening is to correct a minor clerical error or omission that resulted in an initial claim denial. Staff can conduct clerical errors reopening via telephone or in writing. However, if a claim includes no clerical or minor errors and you disagree with a Medicare decision or policy, you should appeal.

 If you are uncertain whether the issue on your claim is minor or clerical, the best way to proceed is to initially file for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for a reopening and appeal simultaneously. 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 you believe are incorrectly identified as such
  • Incorrect data items, such as provider numbers, use of modifiers, or dates of service 

Editor’s note: This article is adapted from Observation Services: A Guide to Compliant Level of Care Determinations, Third Edition published by HCPro, Inc.

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