Reopening vs Redetermination

A Reopening is a process used to correct minor errors or omissions to a previously processed claim without using the formal appeals process. A reopening must be requested within one year from the date of the initial determination.

The Redetermination is the first level of appeals. A party who is dissatisfied with an initial determination may request a redetermination. Redetermination requests must be submitted within 120 days from the initial claim determination.

How To File a Reopening Request

• Calling the automated claim corrections via the IVR (Novitas)
• Submitting a written request using the Medicare redetermination and clerical error reopening request form
• Online claim corrections in the Novitas/CGS portal

When to submit a new claim

• No claim on file when checking claim status
• Claim is unprocessable (MA-130)

When not to submit a new claim

• Denied/finalized claim on file
• Claim data needs corrected/updated
• Duplicate denial

Important Links

Novitas Guideliness, Redetermination Form, Reopening Form

CGS Guideliness, Redetermination Form, Reconsideration Form, Reopening Form

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