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Claim reopening Guidelines
Q: What is the difference between a claim reopening and an adjustment?
A: Reopening’s are different from adjustment bills based on the following rules:
• Adjustment bills are subject to normal claims processing timely filing requirements (that is, filed within one year of the date of service).
• Reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed (for example, claim determinations may be reopened within one year of the date of receipt of the initial determination for any reason, or within one to four years of the date of receipt of the initial determination upon a showing of good cause). Reopening’s are only allowed after the normal timely filing period has expired.
Providers that need to correct or supplement information on paid (status/location P/B9997) and/or rejected (status/location R/B9997) claims may refer to the following:
Claim adjustment guidelines
• Providers may submit adjustment claims (type of bill (TOB) xx7) to correct errors or supplement a claim when the claim remains within the timely filing limits.
• Click here for additional information on the timely filing guidelines.
• Click here to review the claim data elements required for adjusting and/or canceling claims.
Claim reopening guidelines
• Prior to January 1, 2016, providers submitted the timely filing exception form for preapproval on claim(s) requiring correction that were beyond the timely filing limit.
• Effective on/after January 1, 2016, providers must utilize the new reopening process (TOB xxQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill is not allowed.
• CMS released special edition MLN Matters® article SE1426 external pdf file, to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.
Examples of timelines for filing adjustments and reopenings:
Timely filing period – Use TOB xx7
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