Medical Review Reopening

7.2.2.4 - Medical Review Reopening (Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS); Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013 (Implementation of VMS) A MR reopening is a remedial action taken to review and change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination for decision was correct based on the evidence in the record. It is separate and distinct from the appeals process. The Contractor may choose to reopen a claim for late documentation. The MR department shall conduct a reopening of claims sent by the appeals department which meet the criteria in IOM Pub. 100-04, Section 10.3. (1) A provider failed to timely submit documentation through an Additional Documentation Request (ADR) (2) Claim was denied because the requested documentation was not received timely (3) the requested documentation is received after the 45 day period with or without a request for redetermination or reopening AND (4) The request is filed within 120 days of the receipt of the initial determination. Do not count more than one reopening per claim.