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Medicare Claims Processing Manual (Pub. 100-04, Ch. 3External PDF).

CGS performs three types of reopenings:

  • Claim Correction Reopening (for claims that require correction beyond the claim timely filing limit)
  • Untimely Filing (for claims rejected (R B9997) or processed (P B9997) with reason code 39011)
  • 56900 Reopenings (for claims denied due to non-receipt of medical record documentation in response to an Additional Documentation Request (ADR)

Review the information below to determine the appropriate reopening request type and process.

Claim Correction Reopening

When the need for a claim correction is discovered, and the claim is beyond the timely filing limit (one calendar year from the "through" date on the claim), a reopening request (type of bill (TOB) XXQ) must be submitted to remedy the error. When a claim requires correction, and the claim is within the timely filing limit, an adjustment (type of bill XX7) may be submitted.

Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of CGS. Minor errors or omissions may include:

  • Transposed procedure/diagnostic codes
  • Incorrect provider number or date of service
  • Inaccurate data entry
  • Mathematical or computational mistakes

Note: Omissions do not include failure to bill items/services, such as late charges. A reopening may be requested to change a claim determination that resulted in an overpayment or underpayment, even though the decision was correct when the claim was processed. Reopenings are separate from the appeals process, and therefore, do not count towards the five levels of appeal.

Note: Reopenings (TOB XXQ) cannot be submitted with a hardcopy (paper) UB-04 claim form. They must be submitted via the 5010 format or entered directly into the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) system.

For reopening requests entered via DDE: From the FISS Main Menu, select Claims Correction (Option 03) and the appropriate Claim Adjustments option. In addition to the usual field locators and the information being adjusted, reopenings (TOB XXQ) must include the following information.

If there is a medically denied line item on the claim, FISS may not allow you to complete the adjustment electronically. If you are unable to submit the reopening electronically or via DDE, you may submit a hardcopy adjustment using the Clerical Error Reopening Adjustment Request FormPDF.

Reminder: If a claim in a P status has been reviewed by Medical Review, and has one or more line items denied, adjustments can be made to the paid line items. Adjustments cannot be made to any part of a denied line item on a partially paid claim.

Field Name/Requirement



(FISS Page 1)


Once the claim is selected, change the third digit of the TOB to 'Q' to identify the claim adjustment as a reopening request.


(FISS Page 1)

Enter the appropriate condition code.

R1 – Mathematical or computational mistake
R2 – Inaccurate data entry
R3 – Misapplication of a fee schedule
R4 – Computer errors
R5 – Incorrectly identified duplicate
R6 – Other clerical error or minor error or omission (failure to bill a service is not considered a minor error).
R7 – Correction other than clerical error
R8 – new and material evidence is available
R9 – Faulty evidence (initial determination was based on faulty evidence)


(FISS Page 1)

Enter a condition code that best describes what is being changed.

D0 – Changes in service date
D1 – Change to charges
D2 – Changes in revenue code/HCPCS/HIPPS Rate Codes
D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes
D9 – Change in condition codes, occurrence codes, occurrence span codes, provider ID, modifiers and other changes
E0 – Change in patient status

When D9 is used, an explanation must be included in the REMARKS field (FISS Page 4).


(FISS Page 1)

Enter 'W2' (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process. A reopening request cannot be submitted if an appeal has been requested, and a decision is pending or in process.


(FISS page 3)

FISS will automatically assign one of the codes below.

R1 – Less than 1 year from the initial determination (Remittance Advice (RA) date)
R2* – 1 – 4 years from the initial determination (RA date)
R3* – Greater than 4 years from the initial determination (RA date)

*Requires "Good Cause" in the "Remarks" field.


(FISS page 4)

Remarks are always helpful in processing a reopening; however, the REMARKS field is required when the R2 or R3 Adjustment Reason Code is submitted. Remarks should be formatted for a change or addition (C-A), new and material evidence (NME) and faulty evidence (F-E) with a narrative explanation. NOTE: The first 15 characters of the remark must match exactly as shown below.

  • Good_Cause-_C-A (underline indicates a space)
  • Good_Cause-_NME (underline indicates a space)
  • Good_Cause-_F-E (underline indicates a space)

Example: Good Cause- C-A to add revenue code 0550 because…

If the change or addition affects a line item, please indicate which line(s) is/are being changed.

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Untimely Filing

Claims are rejected for untimely filing when the claim is submitted 12 months after the date the services were furnished. The Centers for Medicare & Medicaid Services have established exceptions to the one calendar year time limit. For additional information, refer to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70.7External PDF. At this time, a hardcopy UB-04 adjustment, or a reopening request, may be submitted if one of the exceptions apply.

Reason for Untimely Filing

Submitting Hardcopy Adjustment

Submitting a Reopening – Can only be submitted via 5010 or FISS Direct Data Entry (DDE)

Claim rejected (R B9997 or processed (P B9997) with reason code 39011 due to timely filing edits

  • Medicare Clerical Error Reopening Adjustment Request FormPDF
  • Adjustment claim (XX7) on a hardcopy UB-04 claim form,with the necessary adjustment coding (condition code, DCN, and remarks)
  • Documentation to support an exception to override timely filing.

NOTE: To determine the correct DCN to report on your adjustment, select the denied claim. Go to Page 02 and press F2. The DCN of the claim will appear in the upper left corner in the "DCN" field.

Requests for untimely filing reopenings, along with supporting documentation, must be mailed to:

J15 Part A Claims
CGS Administrators, LLC
PO Box 20211
Nashville, TN 37202

Detailed coding information can be found under the "Claim Correction Reporting" heading of this Web page.

  • Condition Codes (R7, R8, or R9)
  • Condition Code D9 (Other Changes)
  • Condition Code W2
  • Adjustment Reason Code (R1, R2, or R3)
  • Remarks (required when adjustment reason code R2, R3, or condition code D9) Refer to the "Remarks" section (above) under the "Claim Correction Reopening" heading.

If additional information is requested by CGS, the reopening adjustment will be RTP'd with a note on the Remarks page. Please note, no letter will be sent by CGS.

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56900 Reopenings

Claims deny with reason code 56900 when a medical review contractor doesn’t receive your documentation in response to an additional documentation request (ADR) letter within the required timeframe (45 calendar days for CGS). Review the Additional Documentation Request Process: What to Send page to learn how to avoid these claim denials.

A 56900 reopening request allows the Medical Review department to complete a review without using the Medicare Appeals process.

When to Submit

  • Claim denied with reason code 56900
  • Within 120 days of the claim denial date
    • After 120 days of the claim denial date, submit a redetermination request (first level of appeal).

How to Submit

What to Submit

  • Completed 56900 reopening request form
  • Copy of the ADR letter
  • Medical record documentation that supports medical necessity of the services billed (as indicated in the ADR letter and/or Part A Medical Review Activity Log)

Updated: 10.20.23

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