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 or known during thedecision 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, inaccurate data entry, and denial of claims as duplicates.
- 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.
Reopening requests made by a member, member’s authorized representative, or a non-contracted care provider, must be:
- Clearly stated;
- Include the specific reason for the reopening;
- In writing, and
- Filed 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 an appeal.
A request for a reopening may occur under the following conditions:
- A binding determination or decision has been issued, and
- The 60-calendar day time frame 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
We offer a peer-to-peer discussion with the Medical Director that made the pre-service determination. Once a pre-service adverse determination has been made, Medicare does not allow the decision to be changed as a result of the peer-to-peer discussion. Any additional information received as a result of that post-decision discussion must be submitted as part of a Medicare Reconsideration (Appeal).
To allow for a change in decision as a result of a peer-to-peer discussion, we have a pre-decision peer-to-peer window for standard clinical denials (excludes expedited and administrative denials). This is for outpatient and inpatient pre-service requests. We reach out to offer a 24-hour window, prior to finalizing a potential adverse determination, to allow for the discussion between the physician and the Medical Director. If additional information is received during this pre-decision peer-to-peer window, the final decision could then potentially result in a changed determination. If the discussion does not happen before the end of the 24-hour window, the decision is finalized and any peer-to-peer discussion that follows is informational only.