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July 9, 2014

Reopening Requests for Services Subject to Medical Review

Reopenings offer Medicare providers access to correct minor or clerical errors outside of the formal appeals process. Services that have been upcoded or downcoded as a result of medical review do not fit into this category and, therefore, cannot be processed as reopenings.

For example:
The provider submits CPT code 99210. A request for the medical record is sent to the provider. Upon review and based on the documentation provided, the service is downcoded to CPT code 99209.

In this situation, if you disagree with the outcome of the review, please submit a request for Redetermination and include any documentation you have to support the higher level of service.

For assistance with determining the type of request to submit, please refer to the Reopening vs. Redetermination Job AidPDF.

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