By Kim Turner, RN
No matter how careful, Medicare claim mistakes will happen. When they do, your claim may not be able to be processed by the DME MAC. Listed below are some common errors which prevent your claim from being processed. If you find a simple mistake, chances are you may be able to make a correction using our telephone reopening line. There is no need to request an appeal/redetermination 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 can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. You can request a reopening for minor errors or omissions either by telephone or in writing.
You have one year to request a reopening from the date on your Remittance Advice (RA).
Examples of minor errors or omissions include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Transposed beneficiary Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer errors
- Incorrect data items, such as the use of a modifier or date of service
Use the telephone or in writing reopening process to resolve minor errors or omissions involving:
- Units of service
- Service dates
- Healthcare Common Procedure Code System (HCPCS) coding
- Diagnosis codes and diagnosis reference
- Modifiers (excluding the KX, GA, GY and/or GZ modifier)
- Place of service
Be sure to wait to call the telephone reopening line or request reopening in writing until you receive your Medicare remittance notice. No action can be taken until a final claim determination is issued.
For more specific details and instructions for reopening based on your DME MAC jurisdiction, click the applicable link:
DME MAC Jurisdiction C
https://cgsmedicare.com/jc/claims/reopenings.html
DME MAC Jurisdiction D
https://med.noridianmedicare.com/web/jddme/claims-appeals/reopening#telephone
The following are examples of what cannot be handled as a Reopening:
- Redetermination requests, which must be submitted via the appeals process
- Untimely filing - Reopenings Requests must be made within one year from the date of initial determination
- Unprocessable/Returned claims (i.e. ANSI code 16) - Resubmit the claim with the corrected information
- Addition, change, and/or removal of KX, GA, GY and/or GZ modifiers
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