MIR-2006-11AB, November 2006

Telephone Reopenings

You may request a reopening of the original claim processing decision by contacting our Telephone Reopening Unit (TRU).

The TRU representatives are available for you to use when you wish to revise the initial determination or redetermination of a specific service or claim for minor clerical errors. If you have a general question or need to talk to someone about an issue that cannot be reopened, our Call Center will assist you. For more details on when you need to direct your questions to the Call Center, refer to the information below under the heading “Issues That Cannot Be Handled on the TRU Lines.”

The TRU representatives will reopen claims to correct minor, uncomplicated, provider or carrier clerical errors or omissions. The TRU line representatives cannot add items or services that were not previously billed. Reopenings are granted at the contractor’s discretion. A decision by the contractor to not reopen a claim is not appealable.

Contacting the TRU

New Jersey providers can call the TRU toll-free at 1-866-620-1190 between the hours of 8:30 a.m.-12:00 p.m. and 1:00-3:00 p.m., Monday through Thursday.

New York providers can reach the TRU toll-free at 1-888-399-7719 between the hours of 9:00 a.m.-12:00 p.m. and 1:00-3:00 p.m., Monday through Friday.

The telephone reopening representative will assist you with up to three claims each time you call.

Information Needed Before You Call the TRU Line

When requesting a reopening over the phone, you must be prepared to provide the following information:

• Beneficiary’s name
• Medicare Health Insurance Claim Number
• Your full name (first and last name)
• Your phone number
• Provider’s name
• Provider’s number
• Date of the initial claim determination or the Internal Control Number
• Date(s) of service in question
• Reason for request

Timeliness

All requests for reopenings must be requested within 365 days of the original claim determination.

Issues That Cannot Be Handled on the TRU Lines:  

• Redetermination requests, which must be submitted in written form.
• Untimely Reopening Requests—A request to reopen a claim that exceeds the 365-day time limit must be submitted in written form.
• Medicare Secondary Pricing (MSP) issues.
• Any claim that requires additional documentation.
• Ambulance inquiries regarding the GY modifier.

NOTE: The above issues must be submitted in writing to the following addresses:

Questions concerning any of the topics listed below should be directed to our Call Center:

• Inquiries on the status of claims in process.
• Unprocessable/Returned Claims—this situation is identified as message MA-130 located on your Provider Remittance Statement.
• Inquiries related to denial of payment based on entitlement—questions concerning entitlement to the Medicare Program or Health Maintenance Organization Coverage.
• Questions that are general in nature and not claim specific.

The following toll-free numbers will connect you with our Interactive Voice Recognition (IVR) phone system.

If you need to speak directly with a Customer Service Representative, please call one of the following toll-free numbers:

CMS Pub. 100-4, Transmittal # 1069, Change Request 4147