Reopening Claims with Additional Information or Denied due

3.2.3.9 - Reopening Claims with Additional Information or Denied due to Late or No Submission of Requested Information (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) Contractors shall make available general reopening process information via their website, in their ADR letters, or through remittance advice notices. If the MACs receive the requested information from a provider or supplier after a denial has been issued but within a reasonable number of days (generally 15 calendar days after the denial date), they have the discretion to reopen the claim. MACs who choose to reopen a specific claim shall notify the provider or supplier of their intent to reopen that claim. Notification to the provider/supplier of the intent to reopen a specific claim shall be completed through any of the following mechanisms: Interactive Voice Response (IVR), contractor website portal, telephone contact, by letter, fax, email or secure messaging within 3 business days of identification of the request to reopen or receipt of medical record documentation. MR will make an MR determination on the lines previously denied due to failure to submit requested documentation, and do one of the following, within 60 calendar days of receiving documentation in the mailroom: • For claims originally selected for post-payment review, the reviewer shall issue a new letter containing the revised denial reason and the information required by PIM chapter 3 §3.6.4; • For claims originally selected for prepayment review, the MAC shall enter the revised MR determination into the shared system, generating a new Medicare Summary Notice (MSN) and remittance advice with the new denial reason and appeals information; • The workload, costs, and savings associated with this activity shall be allocated to the appropriate MR activity (e.g., MR reopenings); In cases where the MAC or UPIC denied a claim and the denial is appealed, the appeals entity will send the claim to the contractor’s MR department for reopening in accordance with CMS Pub. IOM 100-04, chapter 34, § 10.3. The claim sent back to the contractor’s MR department must have been denied using Group Code: CO - Contractual Obligation and 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. The MR department of the contractor (MAC, or UPIC) who initiated the prepayment edit shall be responsible for conducting the reopening. • The MACs who choose not to reopen claims when documentation is received past the deadline shall retain the information (hardcopy or electronic) in a location where it can be easily accessed. If the RAC receives requested documentation from a supplier after a denial has been issued they shall not reopen the claim. • If a RAC receives documentation after the submission deadline, but before they have issued a demand letter, the RAC shall review and consider the late documentation when making a claim determination; • If the RAC receives a late response to a documentation request after they have issued a demand letter, the RAC shall retain the documentation so that it is available for review during the appeal process. For information on how CERT handles late documentation, please refer to Chapter 12, Section 11 Late Documentation Received by the CERT Review Contractor.