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 requests made by a member, member’s authorized representative, or a non-contracted care provider, must be:
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:
Types of determinations or requests that cannot be reopened are as follows:
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.