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Initiate Redeterminations/Clerical Error Reopenings

Understanding the difference between a clerical error reopening versus a redetermination will assist you with the steps to take for quick reimbursement.

Initiate a Redetermination

The redetermination is the first level in the Medicare appeals process.

  1. Select the My Claims tab in the top navigation toolbar, and then click the drop-down arrow in the Claim Menu to select the Claim Type – Claims to initiate a claim search,
  2. The Claims Summary panel will display a list of claims based upon the search criteria entered.
  3. In the Claims Summary panel, locate the claim you wish to initiate a redetermination on and click the Claim Number hyperlink.

    Note: The first ten claim lines will display, you can click the Show More button to view additional claims and you can use the pagination arrows at the bottom of the panel to scroll through the records.

Claioms Summary showing that you have to click on a cliam number to view the claim details.

The Claim Header panel will display first. Scroll down to the Claim Lines panel.

  1. Click the Initiate Redetermination button in the Claim Lines panel.
  2. The Redetermination/Reopening History panel will display a list of all Reopening or Redetermination requests that have been submitted for the claim selected.
      • The first row in the Redeterminations/Reopenings History panel displays the current Redetermination or Reopening you initiated. Note: The Status of the Request will display as ‘In Progress – Not Submitted’.
        • To proceed with the current request, scroll down to the Redeterminations/Reopening Details panel. Complete all required fields and any applicable fields related to the request.
        • If you do not want to proceed with the current request, scroll down to the Redetermination/Reopening Details panel and select the Cancel button.

Claim line details showing that you have to click the Initiate Redeterminations button in the top right of the cliam line applet.

  1. The Redetermination Details panel will display. Enter information in the required fields, and any other applicable fields. Most information will auto-populate based upon the provider and claim selected.
          • Requester’s Name/Signature
          • Requester’s Phone Number – enter a valid telephone number where you can be contacted if we have a question about the request submitted.
          • Reason for appeal – indicate the reason you are requesting the redetermination and why you do not agree with the initial claim determination
          • Late Filing Reason - If the request is past the timely filing limit you must indicate the reason you believe “good cause” exists in this field.

    Redetermination detials screen showing all the fields that have to be completed.

    1. Scroll down to the Claim Lines panel.
    2. In the Claim Lines panel select the claim lines you are appealing, by clicking the checkbox in the Appeal Line? field, to indicate you are appealing the claim line.

    Claim line screen showing that you have to check the appeal line box to appeal that claim line.

    Note: If a claim line has been adjudicated and you agree with the determination the claim line should not be included in the redetermination request.

    Submit Redetermination Request

    1. Scroll back up to the Redetermination Details panel.
    2. Click the Submit button.

    Redetermination details screen showing that once you have added the appeal and attachement you can click the submit button to finish the redetermination submission.

    The following message will display indicating the redetermination request was successfully submitted.

    Redetermination was successfully submitted. Submitting supporting documentation is strongly recommended, go to the Attachments panel, and click on ‘New’ to add your documentation. If documentation is not attached, the decision will be made with the information on file and may result in an unfavorable decision.

    An email verification will be sent to the email address associated with the user profile, acknowledging receipt of the redetermination request.

    Note: You will then need to scroll down to the Attachments panel to attach Supporting Documentation. Submitting supporting documentation is strongly recommended, if documentation is not attached the decision will be made with the information on file and may result in an unfavorable decision.

    Supporting Documentation

    If supporting documentation needs to be included with the redetermination request, scroll to the Attachments panel.

    1. Click the New button in the Attachments panel to add the documentation.
    2. Click the Search icon next to the Attachments Name field, and browse for the additional documentation you would like to submit.

      Note: NGSConnex will accept documentation in .doc, .xls, .pdf, .jpg or .txt format. Video or audio files are not accepted. There are no limits on the number of attachments you may include with your response. It is recommended that you limit the size of the attachment to 25 MB. The Attachment Name should be comprised of letters and numbers. If an Attachment Name includes any special characters you must rename the attachment.

    Attachements screen showing that you have to add an attachement using the new button and then click the add attachement.

    1. Verify you have attached the correct supporting documentation. If you inadvertently added the wrong attachment(s), click the Search icon to save over the attachment.
    2. Click the Save button.

      Note: If you fail to click the Save button the attachments will auto-save.

    Attachments screen showing that once you have added the attachment you have to then click save in order to save the attachment to the appeal of that claim line.

    Note: If you need to add additional documentation after the Redetermination request is submitted you can do so in the My Appeals/Reopenings History tab.

    To initiate another Redetermination request, click the My Claims tab in the top navigation toolbar to initiate a claim search.

    Initiate a Clerical Error Reopening

    Clerical Error Reopenings are used to change the information on the claim or void a claim line to initiate an overpayment. Clerical errors do not include omissions or failure to bill for items or services. You cannot add a claim line that was not previously included on the claim. Third party payer errors do not constitute clerical errors.

    1. Select the My Claims tab in the top navigation toolbar, and then click the drop-down arrow in the Claim Menu to select the Claim Type – Claims to initiate a claim search,
    2. The Claims Summary panel will display a list of claims based upon the search criteria entered.
    3. In the Claims Summary panel, locate the claim you wish to initiate a clerical error reopening on and click the Claim Number hyperlink.

      Note: The first 10 claim lines will display, you can click the Show More button to view additional claims and you can use the pagination arrows at the bottom of the panel to scroll through the records.

    Claim summary screen showing the pagination and the show more button.

    The Claim Header panel will display first. Scroll down to the Claim Lines panel.

    1. Click the Initiate Clerical Error Reopening button in the Claim Lines panel.

      Note:
      If the claim selected is not eligible for reopening, a message will display.

    Claim line screen showing that you can click the initiate a clinical error reopening using the button.

    1. The Reopening Details panel will display. This is where you can make changes to the claim at the claim header level. Information in gray auto-populates based upon the provider and claim selected. Any of the following fields can be updated.
          • Diagnosis Code 1 – 8 – If you add a diagnosis code you must add a diagnosis pointer to the applicable claim line(s). If you delete a diagnosis code that is associated with a claim line you must update the diagnosis pointer for the applicable claim line(s).
          • Date Last Seen
          • Add/Change Referring/Ordering NPI
          • Place of Service Zip Code Change – If you change the place of service code in the Claim Line Details you will be required to enter the corresponding zip code in this field.
          • If you need to make changes or void a claim line, scroll down to the Claim Lines panel. Note: If you need to make changes or void a claim line, you should not click the Submit button until you complete those changes. You will not be able to make changes once the request is submitted.

    Reopening detials showing all the diagnosis fields and dates that need to be completed.

    1. Scroll down to the Claim Lines panel to make changes to a specific claim line.
    2. Select the row containing the claim line that you need to change or void.
    3. Click the Edit button.

    Claim lines screen showing the edit button to edit the claim line for the reopening.

    1. The Claim Lines details applet will display in a separate window.
    2. Click the drop-down arrow in the Claim Line Action field, and select click the drop-down arrow and select ‘Correct Claim Line’ or ‘Initiate Overpayment.’
          • You should select ‘Initiate Overpayment’ if the claim line was billed in error. This will result in the claim line being denied and recoupment of payment.
          • You should select ‘Correct Claim Line’ if you need to make changes to any of the following information on the claim line.
            • From and To Service Date
            • Place of Service
            • Modifier – Modifiers 22, 23, 52, 53, 55, 62, 66, GA, GY, and GZ require documentation and cannot be processed as a clerical error reopening.
            • Diagnosis Pointer – enter a 1 – 8 to indicate the diagnosis you are pointing to in the Reopening Details panel.
            • Units of Service
            • Billed Amount
            • Rendering Doctor NPI
            • Procedure Code

    Claim lines detail screen showing all the fields you can edit and that once you are done editing you have to click the save button.

    1. You can complete steps 2-5 if you have multiple claim lines that need to either be changed or voided.

    Documentation will not be accepted for Part B clerical error reopenings; if additional documentation is required, submit the request as a redetermination.

    Note: If the change you are requesting does not change the initial claim determination the request will be dismissed.

    Submit Clerical Error Reopening Request

    1. Scroll back up to the Reopening Details panel.
    2. Click the Submit button.

    Reopening details showing that once you have completed the process and changes, you have to click the submit button to complete it.

    A message will display indicating the reopening request was successfully submitted. An email verification will be sent to the email address associated with the user profile, acknowledging receipt of the reopening request.

    Note: To initiate another request, click the My Claims tab in the top navigation toolbar to initiate a claim search.

    Initiate Redeterminations/Clerical Error Reopenings
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