Claim Reopening: Request types and tips
| Claim reopening request type | Primary field(s) (required) | Secondary field (optional) | Comments |
|---|---|---|---|
| Edit DOS From | DOS From | N/A | DOS From date may not be later than DOS To date. |
| Edit DOS To | DOS To | N/A | DOS To date may not be earlier than DOS From date |
| Edit DOS Both | DOS From and DOS To |
N/A | Both fields must be changed |
| Edit Diagnosis Code | Diagnosis Code | N/A | The primary diagnosis code may be changed. |
| Edit Procedure Code | Procedure Code | Billed Amount | The replacement code must be one that may be used in a claim reopening request. |
| Add Modifier | Modifier (first available field) |
N/A | Only one modifier may be added, and it must be one that may be used for a reopening request. |
| Edit Modifier | Modifier (any modifier field that contains a value) |
N/A | Only one modifier may be replaced, and it must be one that may be used for a reopening request. |
| Delete Modifier | Modifier (any modifier field that contains a value) |
N/A | Only one modifier may be deleted. |
| Edit Units Billed | Units Billed | Optional fields: DOS From, DOS To, Billed Amount | Anesthesia providers must use units and not minutes when adjusting units billed. The conversion factor is 1 unit = 15 minutes. For example, 75 minutes would be entered as 5 units (75/15=5 units). |
| Edit Billed Amount | Billed Amount | N/A | Note: An adjusted billed amount that is less than the allowed amount for the service is not accepted as it may result in an overpayment. |
Limitations to claim reopenings in the gateway
- Multiple request types (e.g., Edit Procedure Code and Add Modifier) may not be utilized for the same eligible line item
- Line items may not be added or removed
- Certain corrections (e.g., updates to beneficiary information or status) may not be submitted
- Rendering provider’s NPI may not be changed
- Claim reopening requests submitted through the SPOT must be filed within one year of the receipt of the initial determination
- Multiple modifiers, procedure codes, or diagnosis codes may not be added