- Filing an Appeal
- Frequently Asked Questions
- Helpful Websites
- Overpayment Appeals
- Which Form Do I Use?
Instead of a Written Redetermination Consider Having Your Claim Reopened
There is no need to appeal a claim if you have made a minor error or omission in filing the claim, which in turn caused the claim to be denied. In the case where a minor error or omission is involved, you may request that Palmetto GBA reopen the claim so the error or omission can be corrected rather than going through the written appeals process. A reopening may be submitted in written form or, in some cases, over the telephone. A telephone reopening can only be reopened within one year of the date of the remittance unless all lines on the claim are being recouped.
Note: Claims that are rejected as unprocessable (remark code MA130 on the remittance advice) cannot be reopened. Rejected claims must be corrected and resubmitted as a new claim.
What Are Minor Errors or Omissions That Can Be Reopened?
- Incorrect units of Medically Unlikely Edits (MUE) submitted on a claim
- Correct units billed within the MUE
- Reopen a date of service due to receiving two claims for the same service during the same processing period, one claim denied as duplicate and one claim denied for frequency
- Transposed diagnosis (billed 123 but need to change to 321)
- Change a diagnosis pointer on a denied procedure
- Transposed procedure codes (billed CPT code 92136 but need to change to CPT code 91362)
- Change a procedure when it does not change the allowable, i.e., HCPCS code G0008 to G0009
- Downcode a procedure (change to a procedure with a lower allowable)
- Incorrect submitted amount (if it will allow additional payment for the procedure billed)
- Change date of service (month and day only)
- Submission of a claim for services that were not rendered
- Incorrect rendering provider on claim (must verify the PTAN and NPI is associated with the billing group on the claim)
These Are Specific Modifiers That Are Considered Simple Claim Corrections
25, 26, 50, 51, 54, 57, 58, 59, 76, 77, 78, 79 and 91
AA, AD, AT, E1, E2, E3, E4, G8, G9, GV, GW, LT, KD, QJ, QK, QW, QX, QY, QZ, Q3, RT, TC, XE, XP, XS and XU
These modifiers can be added or deleted to a procedure as a simple claim correction when the correction will change the outcome of the overall claim.
Can I Request a Reopening Using the Interactive Voice Response (IVR) System or Through eServices?
Yes, procedure codes that have denied for coverage due to missing CPT modifiers 25, 59 or 79 can be reopened using the IVR or eServices.
Should I Assume Everything Else Must Be Submitted in Writing?
Yes, the claims reopening process is specifically for simple corrections or omissions that do not require additional documentation. More complicated issues must be submitted in writing. The redetermination form is used for the first level appeal and the reconsideration form for the second level appeal. Issues that should not be requested as reopening include:
- Situations involving “Limitation of Liability” (issues involving Advance Beneficiary Notices)
- Claims denied for LCD or NCD (medical necessity)
- Claims that require operative reports and/or clinical summaries (surgery claims submitted with CPT modifier 22)
- Claims that require medical review from our medical staff
- HCPCS modifiers AS and KX, CPT modifiers 80, 82, 52 and 24
- Requests to add items or services not originally submitted to Medicare
- Hospice claims with dates of service that fall outside of the hospice period
- Any Procedure considered to be once in a lifetime (e.g., HCPCS G0438 and G0439)
- Situations involving changes to the patient’s Medicare secondary payer records*
*If your claim denied indicating Medicare is secondary and both local (Palmetto GBA) insurance files and Common Working File (CWF) are updated to show Medicare is primary, this can be adjusted on the “Reopening” line.
There may be instances where an issue cannot be resolved as a reopening, either written or by telephone. An issue may not be resolvable because:
- The issue becomes too complex to be handled as a reopening and/or it is in the best interests of the party to have a more in-depth review performed
- There is a need for additional medical documentation from the provider, physician or other supplier
What Else Should I Know About Reopening Claims?
- When calling the telephone reopening line please be prepared to provide the provider's identifier, the patient's Medicare number, last name and first initial
- Three qualified reopening requests will be allowed per phone call
- This is not to be confused with the 2nd level appeal, also called a reconsideration. Reconsiderations are handled by a separate contractor, the Qualified Independent Contractor (QIC).
- Remember, rejected claims (MA130) must be resubmitted as new claims and do not qualify for reopening
Provider Contact Center hours of operation are 8 a.m. until 4:30 p.m. ET.