CMS requires us to adhere to the appropriate handling of reopenings of our determination. A reopening is a remedial action taken to change a final determination or decision, even though the determination or decision was correct based on the evidence of record.
Reopening Reason Categories:
- New and Material Evidence — documentation that was not previously available and considered during the decision making process that could possibly result in a different decision)
- Clerical Error — includes such human and mechanical errors as mathematical or computational mistakes, inaccurate coding and computer errors.
- Fraud or Similar Fault –post-service decision when reliable evidence shows the decision was procured by fraud or similar fault when the claim is auto-adjudicated in the system.
- Other — includes an error on the evidence in the files was misinterpreted or overlooked in making the decision.
Reopening requests made by a party member, member has authorized representative, or a non-contracted care provider, must be:
- Clearly stated;
- Include the specific reason for the reopening;
- In writing, and
- Files within the prescribed periods.
The request does not have to use the actual term “reopening.” We must process a clerical error as a reopening, instead of reconsideration.
A request for a reopening may occur under the following conditions:
- An adverse decision has been issued, and
- The 60-calendar day timeframe for filing a reconsideration has expired, and
- There is no active appeal pending at any level.
Types of determinations or requests that cannot be reopened are as follows:
- A pre-service determination cannot be reopened for any reason other than for a clerical error, unless the 60-calendar day period to file a Reconsideration has expired.
- Upon receipt of previously requested documentation for a pre-service determination denied due to lack of information, the delegate must consider and submit to us as a reconsideration, unless there is a clerical error.
- A pre-service determination made as part of the appeals process.
- Upon request for a peer-to-peer review following an adverse pre-service determination, if the member, member’s representative, or non-contracted care provider provides new and material evidence not previously known or available, which changes the decision or the rationale for the prior decision, we will not review as a reopening and will provide instructions on how to file a reconsideration;
- A request to review a post-service determination cannot be reopened for any reason (i.e., New and Material Evidence, Error on the Face of Evidence, Fraud or Similar Fault, Other) other than for a clerical error, unless the 60-calendar day time frame to file a reconsideration has expired:
- If a verbal request for review of a post-service determination, we or our delegate may review the request and reopen, if applicable and not already being reviewed as Reconsideration.
Impact on Peer-to-Peer Requests
The post-decision peer-to-peer consult process must conclude for the Medicare population. This requires establishing a pre-decision medical director outreach for standard (14-day turn around time) requests. This includes both inpatient and outpatient adverse determinations. It excludes expedited pre-service requests and administrative denials.
We must treat the following situations as reconsiderations or appeals:
- Clinical information received after notification is complete.
- Peer-to-peer requests received after notification is complete.