decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 12100 / 12100
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Article Overview
This article discusses Medicare carrier policy for reopening and revising Part B claims determinations and decisions. It explains when reopenings may be considered, how they relate to appeal rights, and how requests should be handled when other administrative review processes or SSA jurisdiction apply. The material is aimed at Medicare claims personnel and others working with carrier-level claims administration and appeals procedures.
Why This Topic Matters
Understanding reopening policy helps distinguish discretionary claim review from formal appeal rights and supports consistent handling of late-submitted information, claimant requests, and cases that belong in other review channels.
Article Sections
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Ed. Note: For further information see
A brief editorial reference points readers to related material on reopenings and appeals in another manual chapter.
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12100. Reopening and Revision of Claims Determinations and Decisions
The main section outlines Medicare carrier policy for revisiting prior Part B claim determinations and decisions. It addresses the relationship between reopening, appeals, and hearing-level review, along with general handling of requests and related administrative processing.
What You Will Learn
- How reopening differs from a formal appeal process
- What general circumstances may prompt a claim to be revisited
- How reopening requests interact with appeal rights and hearing procedures
- How to handle requests when another agency has jurisdiction
- What administrative follow-up is described for hearing-related materials
Who Should Read This
- Medicare claims processors
- Carrier medical review staff
- Billing and reimbursement professionals
- Healthcare compliance staff
- Appeals and hearing support staff
Codes Discussed
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