Part A and Part B Reopenings

100.6 – Section E – Part A and Part B Reopenings (Rev. 45, 05-28-04) Report the number of Part A and Part B claims involved in reopenings completed during the month. See §3795 for discussion of what constitutes a reopening. Include reopenings which do not result in revisions. Claims review, reconsideration, Part B hearings, and ALJ hearings undertaken as part of the appeal process are not reopenings. PART A REOPENINGS FALL INTO THE FOLLOWING CATEGORIES: Column (1) Total.--All reopenings completed. Column (2) Pre-Recon.--All reopenings of initial claim determinations. If a claim has been through a reconsideration, do not count it here. Column (3) Post-Recon.--All reopenings of reconsideration determinations. If a claim has been through any type of hearing, do not count it here. Column (4) Post-ALJ Hearing.--All reopenings of ALJ hearing determinations. Once a claim has been through an ALJ hearing, count it here if it is reopened. Line 84. Total Number.--Show the number of claims in which the reopening of a claim, reconsideration, or hearing determination was completed, whether or not the determination was revised. Line 85. Unfavorable to Claimant.--Of the claims shown in line 84, show the number which resulted in a revision of a previously favorable decision. Line 86. No Change.--Of the claims shown in line 84, show the number of claims that you reopened, but on which you did not change the initial determination. Line 87. Favorable to Claimant.--Of the claims shown in line 84, show the number which resulted in a favorable revision of a previously unfavorable decision. Line 88. Amount Awarded.--For cases included in line 87, show the amount of the submitted charges for services which involved a revision of a previously unfavorable decision. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar. PART B REOPENINGS FALL INTO THE FOLLOWING CATEGORIES: Column (1) Total.--All reopenings completed. Column (2) Pre-Review.--All reopenings of initial claim determinations. If a claim has been through a review, or any type of hearing, do not count it here. Column (3) Post-Review.--All reopenings of review determinations. If a claim has been through any type of hearing, do not count it here. Column (4) Post-Hearing.--All reopenings of hearing determinations, regardless of the type of hearing; e.g., intermediary HO or ALJ. Once a claim has been through a hearing, count it here if it is reopened. Line 89. Total Number.--Show the number of claims in which the reopening of a claim, review or hearing determination was completed, whether or not the determination was revised. Line 90. Unfavorable to Claimant.--Of the claims shown in lines 89, show the number which resulted in an unfavorable revision of a previously favorable decision. Line 91. No Change.--Of the claims shown in line 89, show the number of claims that you reopened, but on which you did not change the initial determination. Line 92. Favorable to Claimant.--Of the claims shown in line 89, show the number which resulted in a favorable revision of a previously unfavorable decision. Line 93. Amount Awarded.--For cases included in line 92, show the amount of the submitted charges for services that involved a revision of a previously unfavorable decision. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.