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May 22, 2018Updated 08.19.20

Reopening… or Redetermination???

As a service to you, we have automated the Reopenings process to significantly reduce the amount of time they take to process. In order for automation to work, Reopenings must be submitted on the correct form (whether through myCGS or hardcopy) and the form must be completed accurately. It is equally important that the services submitted as a Reopening are submitted on a reopening request and not a Redetermination request.

Before sending services to be corrected or appealed, please consider the following:

  • Submit a Reopening when a claim that was either paid or denied was processed with minor errors or omissions. Examples include:
    • Date of service correction (within the same year) that do not result in an overpayment
    • Place of service corrections/changes
    • Fixing a transposed CPT/HCPCS code
    • Correcting the number of services (Units)
    • Diagnosis code changes
    • Add, change, or remove some modifiers
    • Correct the billed amount

To submit a Reopening request, please reference the "How to File a Clerical Reopening" article for links to resources and forms.

  • Submit a Redetermination when a claim is denied or partially denied. Examples include:
    • Medical necessity
    • Frequency limitations
    • Review of medical records for claim decision
    • Services submitted with the incorrect YEAR of service
    • Anything that CANNOT be handled as a Reopening

If you need additional information to help you determine whether to submit a Reopening or a Redetermination, please refer to the following resources:

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