US · guidance
CMS Pub. 100-06, ch. 6, § 100.6
Section E – Part A and Part B Reopenings
Report the number of Part A and Part B claims involved in reopenings completed during the
month. See §3795 for discussion of what constitutes a reopening. Include reopenings which do
not result in revisions. Claims review, reconsideration, Part B hearings, and ALJ hearings
undertaken as part of the appeal process are not reopenings.
PART A REOPENINGS FALL INTO THE FOLLOWING CATEGORIES:
Column (1) Total.--All reopenings completed.
Column (2) Pre-Recon.--All reopenings of initial claim determinations. If a claim has been
through a reconsideration, do not count it here.
Column (3) Post-Recon.--All reopenings of reconsideration determinations. If a claim has been
through any type of hearing, do not count it here.
Column (4) Post-ALJ Hearing.--All reopenings of ALJ hearing determinations. Once a claim
has been through an ALJ hearing, count it here if it is reopened.
Line 84. Total Number.--Show the number of claims in which the reopening of a claim,
reconsideration, or hearing determination was completed, whether or not the determination was
revised.
Line 85. Unfavorable to Claimant.--Of the claims shown in line 84, show the number which
resulted in a revision of a previously favorable decision.
Line 86. No Change.--Of the claims shown in line 84, show the number of claims that you
reopened, but on which you did not change the initial determination.
Line 87. Favorable to Claimant.--Of the claims shown in line 84, show the number which resulted
in a favorable revision of a previously unfavorable decision.
Line 88. Amount Awarded.--For cases included in line 87, show the amount of the submitted
charges for services which involved a revision of a previously unfavorable decision. Show
charges prior to application of the deductible and coinsurance. Round results to the nearest dollar.
PART B REOPENINGS FALL INTO THE FOLLOWING CATEGORIES:
Column (1) Total.--All reopenings completed.
Column (2) Pre-Review.--All reopenings of initial claim determinations. If a claim has been
through a review, or any type of hearing, do not count it here.
Column (3) Post-Review.--All reopenings of review determinations. If a claim has been
through any type of hearing, do not count it here.
Column (4) Post-Hearing.--All reopenings of hearing determinations, regardless of the type of
hearing; e.g., intermediary HO or ALJ. Once a claim has been through a hearing,
count it here if it is reopened.
Line 89. Total Number.--Show the number of claims in which the reopening of a claim, review or
hearing determination was completed, whether or not the determination was revised.
Line 90. Unfavorable to Claimant.--Of the claims shown in lines 89, show the number which
resulted in an unfavorable revision of a previously favorable decision.
Line 91. No Change.--Of the claims shown in line 89, show the number of claims that you
reopened, but on which you did not change the initial determination.
Line 92. Favorable to Claimant.--Of the claims shown in line 89, show the number which resulted
in a favorable revision of a previously unfavorable decision.
Line 93. Amount Awarded.--For cases included in line 92, show the amount of the submitted
charges for services that involved a revision of a previously unfavorable decision. Show charges
prior to application of the deductible and coinsurance. Round results to the nearest dollar.
History
(Rev. 45, 05-28-04)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
61af621f5a73150b1044f92fbe1fa56cebec5f458031afeabc9dcdb8744193a9
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