CMS Pub. 100-04, ch. 34, § 10.1

Reopenings can be conducted by a contractor to revise an initial determination, revised

initial determination or redetermination; a Qualified Independent Contractor (QIC) to

revise a reconsideration; an Administrative Law Judge (ALJ) to revise a hearing decision,

and the Appeals Council (AC) to revise an ALJ decision or their own review decision.

Reopenings are generally not conducted until a party’s appeal rights have been exhausted

or the timeframe to file a request for an appeal has expired. There are two exceptions that

allow a reopening to be conducted when appeal rights have not been exhausted or the

timeframe to request an appeal has not expired. These exceptions are:

• Cases where Medical Review (MR) requested documentation, did not receive it,

and issued a denial based on no documentation (i.e., Group Code: CO -

Contractual Obligation; Claim Adjustment Reason Code (CARC) 50 - these are

non-covered services because this is not deemed a “medical necessity” by the

payer; and Remittance Advice Remark Code (RARC) M127 - Missing patient

medical record for this service). Subsequently, if the party requests an appeal and

submits the requested documentation with that appeal, it shall be treated as a

reopening; and

• Clerical errors (which includes minor errors and omissions) shall be treated as

reopenings.

If a contractor receives a valid and timely request for redetermination and begins

processing the request as a reopening (clerical error or otherwise) and later determines

that a reopening cannot be performed, or the determination cannot be changed, the

contractor shall not issue a refusal to reopen notice. Rather, the contractor shall process

the request as a valid/timely redetermination (as originally requested by the party) in

accordance with Pub. 100-04, chapter 29.

If a party has filed a valid request for an appeal, the adjudicator at the lower levels of the

appeals process loses jurisdiction to reopen the claim on the issues in question. For

example, a party simultaneously requests a QIC reconsideration and a reopening with the

contractor. The contractor can no longer reopen that redetermination decision now that

the party has filed a valid request for QIC reconsideration. This does not preclude

contractors from accepting and processing remands from the QIC.

As stated previously, it is within the contractor’s discretion to accept reopening requests,

but once accepted, they must be processed in accordance with the above instruction.