Common reason for adjusting and reopening claims FAQ

Q: What are some common situations when I can or cannot adjust or reopen claims?

A: Providers are responsible in determining when it is appropriate to make corrections to paid (status/location P/B9997) or rejected (status/location R/B9997) claims. Listed below are some helpful hints in determining when you can or cannot correct

Clerical or minor claim error corrections

• Mathematical or computational mistakes
• Transposed providers or diagnostic codes
• Inaccurate data entry
• Misapplication of fee schedule
• Computer errors
• Denial of clams 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

Tolerance guidelines for adjusting hospitals and skilled nursing facilities (SNF) claims

• Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days)
• Blood deductible
• Change in the Part B cash deductible of more than $1.00
• Inpatient hospital cash deductible of more than $1.00
• Servicing hospital or SNF provider number
• Hospital outlier payment
• Discharge status

Adding charges or services

• Providers may adjust claims (TOB xx7) to add charges or services when the claim is within the timely filing period.

• Providers are not permitted to add charges or services on an initial bill after the expiration of the time limitation for filing a claim.

• Click here for additional information on the timely filing guidelines.


Hospital diagnosis related group (DRG) claim adjustments

• Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.

• Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.
Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments

• SNF adjustments to change in HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.

Medically denied claim

• It is not appropriate to adjust claims that have medical review (MR) denials (status/location D/B9997), or paid claims with line item(s) denials.

• Medicare administrator contractors (MACs) will not allow claim lines that have been denied through a MR process (for example, MR, recovery audit contractor (RAC), comprehensive error rate testing (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.

• Click here to review the process on how to determine when a claim was medically reviewed and how to make changes.

• Providers must submit appeal request for claim denials based on medical records, including failure to respond to medical record requests.



Additional reminders

• Do not adjust claims in status/location P/B9996 (payment floor) until they have reached final disposition.
• Claims in status/location P/B7516 or R/B7516 (Medicare secondary payer post pay) will be held for at least 75 days (CMS cost avoidance savings), and cannot be adjusted until they have reached final disposition.
• Third party payer error in making primary payment does not constitute “good cause” for the purpose of reopening a claim beyond one year of the initial determination.
• A contractor’s decision to reopen or not reopen a claim, regardless of the reason for the decision, is not subject to an appeal.
• A reopening will not be granted if an appeal decision is pending or in process.

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.

• Examples of timeliness for filing claim adjustments:

Timely filing period – Use TOB xx7

Claim “through” date Remittance advice date Adjustment period (based on “through” date)

10/01/14 11/01/14 11/02/14 – 09/30/15

10/01/14 03/31/15 04/01/15 – 09/30/15

10/01/14 09/30/15 N/A – timely filing period has elapsed

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 billing electronic media (EMC) or direct data entry (DDE) claims 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.

• In an effort to streamline and standardize the process for claim reopening with the ‘Q” frequency code and adjustment reason codes (ARC), the Centers for Medicare & Medicaid Services (CMS) issued

• Examples of timelines for filing claim reopenings:

Beyond timely filing period – Use TOB xxQ

Claim “through” date Remittance advice date Reopening period – ARC=R1 (based on RA date) Reopening period – ARC=R2 (based on RA date) Reopening period – ARC=R3 (based on RA date)

10/01/14 11/01/14 10/01/15 - 10/31/15 11/01/15 - 10/31/18 11/01/18 and beyond

10/01/14 03/31/15 10/01/15 – 03/30/16 03/31/16 – 03/30/19 03/31/19 and beyond

10/01/14 09/30/15 10/01/15 – 09/30/16 10/01/16 – 09/29/19 09/30/19 and beyond