CMS Pub. 100-04, ch. 34, § 10.5.2

Telephone reopenings shall be limited to resolving minor issues and correcting errors as

defined in §10.4. As necessary, the contractor may ask the provider, physician, or

supplier to fax in documentation to support changes and error correction. If it appears

extensive documentation is required for review, please inform the requestor that they

should file a written request for reopening or file a request for an appeal, if applicable.

Telephone reopenings are generally inappropriate for the following issues:

• Limitation on liability;

• Medical necessity denials and reductions; or

• Analysis of documents such as operative reports and clinical summaries.

Contractors are not precluded from conducting a reopening on the issues listed above.

However, CMS believes that the issues above are usually too complex to be handled

appropriately over the phone in most instances.

In all cases, telephone reopenings are inappropriate for the following issues: Claims

requiring the input of medical staff or other entities outside of the reopenings department

and “big box” cases.

A. Issues That Can Not be Resolved During the Telephone Reopening

There may be instances where an issue cannot be resolved during the telephone

reopening. An issue may not be resolvable on the telephone because: (1) the issue

becomes too complex to be handled over the telephone and/or it is in the best interest of

the party to have a more in-depth review performed; or (2) there is a need for additional

medical documentation from the provider, physician, or other supplier.

If the issue cannot be resolved due to one of the preceding reasons, the contractor advises

the party that the reopening cannot be handled over the telephone. The contractor shall

instruct the party to either file a written request for reopening or file a written request for

appeal. Instruct the party that appeal requests must be filed within 120 days from the

date of the initial determination.