By Kelly Grahovac, The van Halem Group
The word “reopening” has different meanings, depending on what side of the fence you may fall. If you are speaking to your local DMEMAC customer service representative, they may suggest that a reopening is in order for claim submissions that contained a mistake or minor error. And yes, this is true. There are times that you may have transposed a number or letter, resubmitted a claim that resulted in a duplicate denial or made some other mistake that can fall into the human error category. But what happens when the human error falls on the side of the contractor?
In various speaking engagements, I often receive the same question: “What can I do when the Redetermination decision is wrong?” Now before I go any further, let me clarify this question. Of course, the natural inclination is to think the decision is wrong when it comes back unfavorable isn’t it?! I mean, you provided the necessary equipment to the beneficiary so, naturally, it should be covered! To consider the Redetermination decision to be wrong would be when referring to the “Explanation of the Decision” section of the decision letter. For example, the section contains inaccurate information, such as an item being detailed as missing or invalid, when it is not.
So how do you handle this when it happens to you? First and foremost, be sure that you are correct. What I mean is, do you have the necessary proof to indicate that the decision was wrong? If you submitted the appeal request via fax, you need to be sure that you have the fax confirmation to include all the pages that were submitted. If your appeal request was submitted in the mail, you need to be able to detail the number of pages submitted and which page number(s) included in the document are in question. In the most general of terms, can you prove that the documentation was received at the contractor in its entirety? If so, then let’s proceed to step two.
Upon discovering that the Redetermination decision contained an error, you need to bring that to the attention of the contractor. First and foremost, do this in writing. In the past, you were able to contact a customer service representative who could pull up your scanned appeal submission, verify the inaccuracy and then request the reopening on your behalf. Gone are those days! In speaking with various contacts at the DMEMACs, customer service representatives are no longer able to assist on this level. But do not fret! This does not stop the reopening from happening, it just adds another level for you to move through.
You have the right, by law, to request that the appeal decision be reopened. The CMS Internet Only Manual 100-04, Chapter 34, Section 10.1 states that “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.” And further, the IOM goes on to say that good cause exists when the evidence that was considered in making the determination or decision clearly shows on its face that an obvious error was made at the time of the determination or decision.
Upon discovering the contractor error and verifying that you have the necessary proof to be proceed, the third step in the Reopening process is to include all the necessary details in your request. When bringing an error to the attention of the contractor, be sure that you do the following:
- Make your request in writing
- Include the following elements:
- Clearly state that it is a “Request for a Reopening of a Redetermination/Reconsideration Decision”
- Redetermination DCN/QIC Appeal #
- Reason for Reopening
- Documentation to support reopening
- Submit the request to the Appeals address
Lastly, know that the contractor’s decision to reopen is based on the existence of good cause. They also have the right to refuse to reopen after determining that good cause does not exist. Understand that the timeline to request the next level of appeal does not stop for a reopening. This is very important. Please pay attention to timelines and do not assume that your request for a reopening stops the deadline to the next level of appeals. Should the contractor refuse to reopen the appeal remember that you still have appeal rights to the next level, however, the clock begins from the date of your initial decision letter.
Remember, a reopening is a valid request, no matter what step in the claims process you fall. And when your appeal request is not handled appropriately, you are entitled to a reopening. Be sure that you have the appropriate evidence to support the need for the request and that it is submitted accordingly and to the appropriate department. We all make mistakes, both supplier and contractor. The reality is that we appreciate the human attention taken to our reviews, but with human attention comes the probability for human error. Should you find that an error has occurred in your appeal, you do have the right to have it corrected. Take care of details and pay attention to timeliness deadlines to be successful.