Reopenings and Revisions of Claims Determinations and Decisions -

10 - Reopenings and Revisions of Claims Determinations and Decisions - General (Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16) A reopening is a remedial action taken to change a binding determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are separate and distinct from the appeals process. Reopenings are a discretionary action on the part of the contractor. A contractor’s decision to reopen a claim determination is not an initial determination and is therefore not appealable. Requesting a reopening does not toll the timeframe to request an appeal. If the reopening action results in a revised determination, then new appeal rights would be offered on that revised determination. Under certain circumstances a party may request a reopening even if the timeframe to request an appeal has not expired. Historically, contractors have employed a variety of informal procedures under the general heading of “reopenings,” “re-reviews,” “informal redeterminations,” etc. Providers, physicians and suppliers may have come to view these as appeal rights. However, as stated above, reopenings are separate and distinct from the appeals process. They are not a party’s right. Contractors shall not use them to provide an appeal when a formal appeal is not available. Contractors should also note that while clerical errors must be processed as reopenings, all decisions on granting reopenings are at the discretion of the contractor. Contractors may conduct a reopening to revise an initial determination or redetermination. Medicare Secondary Payer (MSP) recovery claims where the debtor is the beneficiary or provider/supplier are not reopening actions except where the recovery claim is a MSP provider/supplier recovery claim because the provider/supplier failed to file a proper claim as defined in 42 CFR Part 411. Aside from this one exception, MSP recovery claims involve recovery of the insurance funds at issue, not recovery of the payment previously made by Medicare. Consequently, the recovery action does not involve the reopening of Medicare's payment determination. The MSP recovery demand letter is an "initial determination" as defined in 42 CFR 405.924, not a reopening and revision of Medicare's initial claims payment determination.