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Saturday, March 5, 2016

Medicare denial claim reopen from SPOT

Claim reopening: Request types

What types of changes may I include in a claim reopening request? May I change more than one field on each line item? Can I add or remove line items?

The only form of claim reopening request that may be submitted through the SPOT is a Part B clerical reopening.

• If a line item of a claim is considered eligible for reopening, corrections may be made to the following fields:
• Date of Service (DOS)
• Diagnosis Code (primary)
• Procedure Code
• Modifier
• Units Billed
• Only one Claim Reopening Request type may be selected for each eligible line item, and the type of request is determined by the primary field to be corrected.
• Some types of requests may allow the editing of more than one field (i.e., primary and secondary fields). However, the primary field is based upon the request type selected, and the primary field is always a required field.


Medicare denial claim reopen from SPOT


    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 N/A Both DOS fields must be changed
and DOS To
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  N/A Only one modifier may be added, and it must be one that may be used for a reopening request.
(first available field)
Edit Modifier Modifier  N/A Only one modifier may be replaced, and it must be one that may be used for a reopening request.
(any modifier field that contains a value)
Delete Modifier Modifier  N/A Only one modifier may be deleted.
(any modifier field that contains a value)
Edit Units Billed Units Billed 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).


            Limitations to claim reopenings on the SPOT

• 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
• History 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 through the SPOT
• Claim reopening requests without any changes may not be submitted through the SPOT

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