US · guidance
CMS Pub. 100-06, ch. 6, § 360.4
Section C - Reopenings (Claim Counts)
B3-13410.4
The carrier reports the number of claims (as defined in §§3000-3000.2) involved in reopenings
completed during the month. (See The Medicare Claims Processing Manual, Chapter 30,
Beneficiary Correspondence and Appeals) for discussion of what constitutes a reopening.) Claims
review, hearings, and ALJ hearings undertaken as part of the appeal process are not considered
reopenings.
Reopenings fall into the following categories:
Column (1) Total - The number of reopenings completed.
Column (2) Pre-Review - The number of reopenings of initial claim determinations. If a claim
has been through a review or any type of hearing, the carrier does not count it here.
Column (3) Post-Review - The number of reopenings of review determinations. If a claim has
been through any type of hearing, the carrier does not count it here.
Column (4) Post-Hearing - The number of reopenings of hearing determinations regardless of the
type of hearing e.g., carrier HO or ALJ. Once a claim has been through a carrier hearing, it is
counted here if it is reopened.
Line 63. Total - The number of claims for which the carrier completed the reopening of a claim
determination, review determination, or hearing determination, whether or not the determination
was revised.
Line 64. Unfavorable to Claimant - Of the claims shown in line 63, this is a count of those that
resulted in an unfavorable revision of a previously favorable decision.
Line 65. No Change - Of the claims shown in line 63, these are those that the carrier reopened but
did not revise the initial determination.
Line 66. Favorable to Claimant - Of the claims shown in line 63, these are those that resulted in
a favorable revision of a previously unfavorable decision.
Line 67. Amount Awarded - For cases included in line 66, the carrier shows the amount of
allowed charges for services that involved a revision of a previously unfavorable decision. It
shows charges after reasonable charge reductions but prior to application of the deductible and
coinsurance amounts. (If the reopening involved a reasonable charge reduction, it shows the
additional amount allowed.) It rounds results to the nearest dollar.
History
(Rev. 6, 08-30-02)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
49a6be1c20cf63ec25632a6fd5e20fcb342924d0e7a2efaa81d4ef39d3864d8e
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