NHIC Corp. JURISDICTION 14 A/B MAC

A Clerical Error Reopening request should be requested as a telephone reopening or written reopening. Examples of reopening issues include:

• Mathematical/computational errors
• Transposed diagnosis and procedure codes
• Inaccurate data entry
• Carrier Errors
• Addition of an add-on procedure code (e.g., codes with global days of ZZZ)
• Misapplication of fee schedule
• Inaccurate duplicate denial (not a true duplicate)
• Incorrect performing provider identification number in Item 24K
• Ambulance errors (transposed zip code; origin/destination modifiers)
• Modifier error: 24, 25, 26, 57, 78, 79, TC, KX, GV, GW, QW, QB, QU, AR, AQ, AT, SG.

The addition of 54 and 59 modifiers can be reopened as a written request only. Correction to a CLIA number can be reopened as a written request only. Please Note: Claims rejected with remark code MA130 do not qualify for a redetermination and cannot be processed as a reopening. A corrected claim must be resubmitted.

A Redetermination should be requested for these situations:

• Limitation of liability issues (frequency, diagnosis, medical necessity)
• National Coverage Determinations (NCDs)
• Medical necessity denials for ambulance transports
• Analysis of documents such as operative reports, progress notes, consultation notes and radiology notes
• Duplicate charge – 76/77 modifier request
• Services that deny as routine
• Screening procedures
• Cosmetic surgery
• Requests for additional allowance (modifier 22)
• Procedures not deemed to be proven effective
• Addition of modifiers 22, 50, 51, 53, 55, 56, 58, 62, 66, 76, 77, 91, LT, RT
• A request disputing a recoupment