REOPENINGS
Use the telephone reopening process to resolve clerical, minor errors or omissions as follows:
Be prepared to have the following documentation available when contacting Medicare’s Reopening Unit…
1) Beneficiary’s Medicare Number
2) Beneficiary’s Name
3) Date of Service
4) Claim Control Number
5) NPI Number
6) Provider Transaction Access Number (PTAN)
7) Last 5 digits of Tax ID Number (TIN)
Additionally you should have the HCPC Codes for the Items in question, dates of service of the claim, and the reason for the request.
Reopenings can be faxed using the “Medicare DME MAC Reopening Request Form” found at : https://www.noridianmedicare.com/dme/forms/docs/nas_reopen_dme.pdf. Note: all DME MAC regions share the same form.
Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Medicare contractors that educate Medicare suppliers, process claims and claim reopenings, and perform first level claim appeals called redeterminations.
Key Links:
Key Links:
Key Links:
Table 1: Reopening DME MAC Contact Information
DME MAC | Hours of Availability | Telephone | Fax | |
Region A | Monday–Friday
| 866-419-9458 5 claims per call permitted | 701-277-2425 | Noridian JA DME
|
Region B
| Monday–Friday
| 844-240-7490 5 claims per call permitted | underpayment fax 615.660.5978 overpayment fax 615.782.4508
| CGS Administrators, LLC |
Region C | Monday–Friday
| 866-813-7878 5 claims per call permitted | 615-782-4649
| CGS DME MAC Jurisdiction C
|
Region D | Monday–Friday | 877-320-0390 5 claims per call permitted | 701-277-7886 | Noridian JD DME
|
Table 2: Appeal Levels and Process
| Level 1 Redetermination | Level 2 Reconsideration | Level 3 Administrative Law Judge – ALJ | Level 4 Departmental Appeals Board – DAB | Level 5 Federal Court |
Time Limit for Filing | 120 days from date of receipt of the notice initial determination | 180 days from date of receipt of the redetermination | 60 days from the date of receipt of the reconsideration | 60 days from the date of receipt of the ALJ hearing decision | 60 days from the date of receipt of DAB decision or declination of review |
Amount in Controversy | No minimum (none) | No minimum (none) | At least $140 remains | No minimum (none) | At least $1,300 remains |
Where to File Appeal | DME MAC (mail or fax) * See Table 3, below for Address/Fax information for the DME MACs.
All 4 regions use the same form | Qualified Independent Contractor (QIC)
RiverTrust Solutions, Inc. | Health and Human Services Office of Medicare Hearings and Appeals (OMHA) field office | DAB or ALJ hearing office |
|
The “Medicare DME MAC Redetermination Request Rorm” Note: all DME MAC regions share the same form.
Helpful guide from CGS titled Reopening vs. Redetermination Job Aid
On March 2, 2015 OMHA announced the implementation of the ALJ Appeal Status Information System (AASIS) Website. The AASIS website provides public access to appeal status information and is accessed through the OMHA website (http://www.hhs.gov/omha) by selecting the “Appeal Status Lookup” link located on the left navigation bar. Information on data availability, updates, and status definitions, is also provided to assist with your search.
AASIS allows users to query level 2 and/or level 3 appeal numbers and returns appeal data such as:
Table 3: Redetermination DME MAC Contact Information
Region A | Region B | Region C | Region D |
Noridian JA DME | CGS | CGS | Noridian JD DME |
For Overnight Delivery use: Noridian JA DME
|
|
| For Overpayment Redeterminations Noridian JD DME
|
Fax:701-277-2425 | Fax: 615.660.5976 | Fax: 615-782-4630 | Fax: 701-277-7886
|
When a Redetermination is filed it is imperative that you review all documents prior to submission to ensure they are applicable and meet CMS guidelines. Note that if you do not feel fully prepared for the Redetermination and you are close to the 120 day filing limit you should consider submitting the Redetermination even though you may be denied. CMS is stringent on the filing limit so it is better to submit the documentation you have knowing that you may have to go to Reconsideration to file the additional documentation once obtained.
Redetermination requests should include the following:
In order to support the case for a specific therapy additional documentation may be necessary and may include:
|
External Infusion Pump/Covered Drugs
|
Immunosuppressive Drugs
|
Parenteral/Enteral
|
Appeal Tips:
Additional Documentation
The suggested documentation items listed here are just that – suggested. It is important that you read the audit and submit all documentation requested in that audit. If you feel additional documentation not requested would help support your claim then you should submit it. In an appeal situation, you should determine which pieces of documentation will best support your appeal.
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