Where the supplier has made a minor error or omission in filing the claim, which in turn causes the claim to be denied, the supplier should not request a redetermination. In the case where a minor error or omission is involved, the supplier can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. Suppliers can request a reopening for minor error or omissions either by telephone or in writing. Suppliers have one year to request a reopening from the date on the remittance notice.

Examples of minor error or omissions include:

• Mathematical or computational mistakes
• Inaccurate data entry, or
• Denial of claims as duplicates which the supplier believes were incorrectly identified as a duplicate

In situations where a provider, supplier, or beneficiary requests a redetermination and the issue involves a minor error or omission, the durable medical equipment Medicare administrative contractor (DME MAC) will treat the request as a request for a reopening.

Because some issues are more complicated than others and may require more research time or consultation with medical staff, the DME MAC reserves the right to decline the telephone reopening and may request that the supplier submit a written redetermination request.

Telephone Requests for Reopenings

The DME MAC telephone reopening number is 317-841-1307.

1. Use the telephone 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
• Place of service
• Claim incorrectly denied as duplicate charges

2. Suppliers should wait to call the telephone reopening line until they have received their Medicare remittance notice. No action can be taken until a final claim determination is issued.

3. Suppliers should consult the Jurisdiction B DME MAC Supplier Manual and applicable medical policy guidelines before contacting the telephone reopening number. Failure to have the appropriate information available when contacting the telephone reopening line may result in an unfavorable decision.

4. Questions about the status of a claim or general Medicare payment and coding questions should not be directed through the telephone reopening line. Suppliers can obtain a claim status report through the Interactive Voice Response (IVR) system or by using Claim Status Inquiry (CSI).

5. The supplier must have the following information available before placing the call for a telephone reopening:

• Medicare supplier number
• Medicare Claim Control Number (CCN) and reason for denial
• Beneficiary name and Medicare Health Insurance Claim number (HICN)
• Any additional information to support why they believe the decision is not correct. This includes having the correct procedure code(s), modifier(s), diagnoses, units of service, etc.

All medical information provided to the DME MAC must be documented in the patient’s file and available to the DME MAC should an audit be required.

If a previous reopening decision has been issued, a redetermination must be made in writing. If a previous redetermination decision has been issued, a reconsideration must be filed.

To effectively service all suppliers, each call will be limited to three claim issues.

Written Requests for Reopenings

Mail all written reopening requests to the following address:

Jurisdiction B DME MAC Redeterminations
P.O. Box 6036
Indianapolis, Indiana 46206-6036

Be sure to include the following information with the reopening request:

• Beneficiary’s name
• Beneficiary’s Medicare Health Insurance Claim number (HICN)
• Specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
• Name and signature of the person filing the request

Reopening requests for break in service issues, Certificate of Medical Necessity (CMN)/DME Information Form (DIF) extensions, and other CMN/DIF changes are not permitted. These types of requests usually require a supplier to submit or fax copies of CMNs/DIFs, delivery and pick-up information, and other documentation before a final determination can be made; therefore, these must also be submitted as a redetermination request.

Phone counselors must devote significant time researching claim history and CMN/DIF status for these issues. This process would tie up incoming phone lines and create long waits for other suppliers attempting to use the telephone reopening lines.