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July 13, 2018

Medical Review Claim Reopenings

Medicare contractor Medical Review (MR) departments may reopen claims for review if late documentation is received after the claim denied due to non-response following an Additional Documentation Request (ADR). Once the late response is received, CGS DME MAC MR automatically forwards the document to consider for a reopening. There is no formal request process for an MR reopening; so, suppliers may simply send the late response according to the directions in the ADR.

In order for an MR reopening to be performed, the claim must have been originally denied due to non-response to the ADR and the response has to be received within a reasonable number of days.

Medicare contractors have 60 days to complete the reopening. Once the new decision has been made, the claim will be adjusted to apply the new decision.  Notification is sent to the supplier in the form of an adjusted claim on a Remittance Advice.

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