Denial and Reopening Timeframes - (Rev. 4, 07-18-03)

7102 - Denial and Reopening Timeframes - (Rev. 4, 07-18-03) A. Initial Denial Determinations and DRG Assignment Changes Render an initial denial determination or DRG assignment change within one year of the payment date of the claim containing the service(s) in question (see 42 CFR 476.96(a)(1)). If the RO approves the action in writing, you may render an initial denial determination or DRG assignment change after one year but within four years of the payment date of the claim containing the service(s) in question (See 42 CFR 476.96(b)(1)). NOTE: These timeframes also apply to technical denial determinations. Issue notices to all appropriate parties as specified in §§7105-7115. Process reconsideration requests as specified in §§7400-7440. B. Reopening of Initial Denial Determinations and DRG Assignment Changes Conduct reopening as specified below. Issue notices to all appropriate parties if the reopening results in a change in your initial denial determination or a change in DRG assignment (See §§7105-7115).  Reopening Within One Year -- You may reopen an initial denial determination or DRG assignment change within one year of the date of your decision (See 42 CFR 476.96(a)(2)). NOTE: You may reopen a technical denial determination within one year of the date of your decision when you deny the claim for lack of medical record information and the information is subsequently provided (Do not reopen any other types of technical denial determinations).  Reopening After One Year But Within Four Years -- You may reopen an initial denial determination or DRG assignment change after one year but within 4 years of the date of your decision if (See 42 CFR 476.96(b)(2)): • You receive additional information on the patient's condition that affects the basis of the prior decision; NOTE: The additional information is generally part of the medical record for the stay in question. There may be exceptions such as additional information related to other hospital stays, physician notes, etc. Addendum orders (i.e., where the physician did not order a service/procedure and retroactively writes such an order) are not considered "additional information." • Reviewer error occurred in interpretation or application of Medicare coverage policy or review guidelines; • There is an error apparent on the face of the evidence upon which the initial denial or DRG assignment change was based; or • There is a clerical error in the statement of the initial denial determination or DRG assignment change. NOTE: You may reopen a technical denial determination after one year but within four years of the date of your decision when you deny the claim for lack of medical record information and the information is subsequently provided (Do not reopen any other types of technical denial determinations).