Authority to Conduct a Reopening

10.1 - Authority to Conduct a Reopening (Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16) Reopenings can be conducted by a contractor to revise an initial determination, revised initial determination or redetermination; a Qualified Independent Contractor (QIC) to revise a reconsideration; an Administrative Law Judge (ALJ) to revise a hearing decision, and the Appeals Council (AC) to revise an ALJ decision or their own review decision. Reopenings are generally not conducted until a party’s appeal rights have been exhausted or the timeframe to file a request for an appeal has expired. There are two exceptions that allow a reopening to be conducted when appeal rights have not been exhausted or the timeframe to request an appeal has not expired. These exceptions are: • Cases where Medical Review (MR) requested documentation, did not receive it, and issued a denial based on no documentation (i.e., Group Code: CO - Contractual Obligation; Claim Adjustment Reason Code (CARC) 50 - these are non-covered services because this is not deemed a “medical necessity” by the payer; and Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for this service). Subsequently, if the party requests an appeal and submits the requested documentation with that appeal, it shall be treated as a reopening; and • Clerical errors (which includes minor errors and omissions) shall be treated as reopenings. If a contractor receives a valid and timely request for redetermination and begins processing the request as a reopening (clerical error or otherwise) and later determines that a reopening cannot be performed, or the determination cannot be changed, the contractor shall not issue a refusal to reopen notice. Rather, the contractor shall process the request as a valid/timely redetermination (as originally requested by the party) in accordance with Pub. 100-04, chapter 29. If a party has filed a valid request for an appeal, the adjudicator at the lower levels of the appeals process loses jurisdiction to reopen the claim on the issues in question. For example, a party simultaneously requests a QIC reconsideration and a reopening with the contractor. The contractor can no longer reopen that redetermination decision now that the party has filed a valid request for QIC reconsideration. This does not preclude contractors from accepting and processing remands from the QIC. As stated previously, it is within the contractor’s discretion to accept reopening requests, but once accepted, they must be processed in accordance with the above instruction.