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The Clerical Error Reopening (CER) process allows Part B providers to correct minor errors or omissions on claims processed in the Multi-Carrier System (MCS). The WPS Government Health Administrators Portal allows providers to make changes to certain claim information on a processed claim and receive immediate notification that the claim adjustment has been accepted into MCS.

Situations that Can Be Handled as a Clerical Error Reopening

In most cases, the following situations can be processed as a CER:

• Increase number of services or units (without an increase in the billed amount) 
• Add/Change/Delete modifiers such as 24, 25, 54, 57, 58, 59, 76, 78, 79, 80, 95, AS, AQ or GA (Note: Post operative modifiers 24, 25, 57, 58, 78 and 79 can be added to a paid claim so the provider can submit a procedure code without having it reduced by the unrelated visit.)
  • Excluded modifiers: 22, 23, 53, 55, 62, 66, 74, and CR present on the claim, even if this is not the line being adjusted. 
• Procedure Codes
  • Excluded: Not Otherwise Classified codes and drug codes present on the claim, even if this is not the line being adjusted 
• Place of service
• Add or change a diagnosis. 
• Billed amounts (without an increase in the number of units billed) 
• Change Rendering Provider National Provider Identifier (NPI)
• Date of service. The date of service change must be within the same year.

Situations that Cannot Be Handled as a Clerical Error Reopening

CMS regulations do not allow a Medicare contractor to process a claim reopening if the change would require Medicare to make a new claim determination. If the change would require a new claim determination, providers should usually request a redetermination (appeal) instead of performing a reopening. Situations that cannot be handled as a CER in the portal:

• Adding lines of service not submitted on the original claim (Medicare would have to make a new (initial) claim determination on the additional services.)
• Increasing both the number of services and the billed amount (In effect, this would be adding services to the claim.)
• Reopening an unprocessable (rejected) claim (Unprocessable claims have not had an initial claim determination, so they would require a new claim determination. Submit a new claim to correct an unprocessable claim.)
• Comprehensive Error Rate Testing (CERT) issues
• Provider Enrollment issues 
• Claim denial due to no response to a development request 
• Wrong payee situations
• Complex claim situations (Not Otherwise Classified codes, claims with modifiers 22, 23, 53, 55, 62, 66, 74, or CR.) 
• Claims that require analysis of documentation 
• Issues that require CMS input (e.g., services after date of death)
• Adjusting a previously adjusted claim

In addition, providers can only reopen a claim once via the WPS Government Health Administrators Portal, so it is important to update all applicable fields before submitting the CER. (For example, you cannot submit a CER to change the date of service and then submit another CER to correct the diagnosis code once the adjustment is finalized.)

Time Limit for Requesting a Clerical Error Reopening

A provider, physician, or supplier may request a reopening up to one year from the receipt of the initial Remittance Notice. If the provider, physician, or supplier would like to request a reopening after the one-year time limit has expired, they may request the reopening in writing.

You must include documentation supporting good cause to waive the timeliness requirement. See the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 34 - Reopening and Revision of Claim Determinations and Decisions , section 10.11 for information regarding good cause.
 
You can use our Reopening Calculator to find the deadline for submitting a reopening request.

Submitting a CER through the Portal

Step 1: All CERs begin by locating the claim in the portal using the Claim Inquiry function. Once you locate the claim, start the reopening by clicking on the CER or Reopen (Clerical Error) button. You can find these buttons in the following places:

• On the Claim Results page after searching for the claim using the Claim Inquiry function
  
   
• In the Claim Actions area after selecting the claim in the Claim Results
  
   
• In the Claim Details section of a denied claim after clicking on the More Info button
  

NOTE: If the claim is not eligible for a Clerical Error Reopening, the CER/Reopen (Clerical Error) button will not be active, and you will not be able to select it.

Step 2: The CER/Reopen (Clerical Error) button opens the Edit Claim – Clerical Error Reopening form. Make all necessary changes to the claim. 

• If you update the billed amount, the portal will ask if the if the change is a “Fee Schedule Change.” 
  • Select Yes if the change is due to Medicare updating the amount it allows for the procedure code.
  • Select No if you are updating the billed amount for any other reason.

 

Step 3: Click the Review button to have portal review the claim for errors. If the changes pass the review, the portal will display the message, “Your information has been successfully reviewed, to finalize your adjustment request, click the Submit button.” (See below for errors that may cause the claim to fail the review.) 

If you need to make corrections, click the Edit button to make changes, or click the Cancel button to cancel the reopening request.

Step 4: Once you are satisfied with the updates to your claim, click the Submit button. The portal will display the confirmation page, which contains the new claim number. 

Common CER Error Messages and Their Causes

Claim processed more than 1 year ago. Reopening not allowed unless good cause can be established. Please see IOM 100-4 Chapter 34 Section 10.11 to determine if good cause exists. If so, submit request in writing with good cause documentation.
Cause: Medicare allows claim reopenings within one year of the initial claim determination for any reason. Medicare can also allow claim reopenings within four years but only if good cause exists (as defined by CMS) to perform the reopening. For reopenings requested more than one year after the initial determination, providers must submit the request in writing to provide documentation proving the good cause requirement is met.

Claim has been previously adjusted, please submit a redetermination request. 
Cause: Claim has been previously adjusted due to a reopening or a previous redetermination. Proceed to the next appropriate level of appeal to request an adjustment to the claim.

Procedure code not valid or Place of Service not valid for Procedure code - reopening not allowed for this change.
Cause: The place of service does not match the procedure code billed, or the procedure code is not valid. Since the information would cause the claim to deny again, a reopening cannot be completed.

Requested diagnosis code is invalid, please recheck diagnosis code. No reopening allowed for invalid diagnosis code.
Cause: An invalid diagnosis code will cause the adjustment to deny.

Claim cannot be reopened because there is no initial determination for this claim. Please submit a new corrected claim or wait until the claim in process has finalized.
Cause: Medicare can only reopen a claim with an initial determination that has finalized. If the claim was rejected as unprocessable (i.e., the remittance advice shows remark code MA-130), it has never had an initial determination, and you should submit a new claim with the necessary corrections. If the claim is still in a pending status, it has not finalized, you will need to wait to request a reopening until the claim finishes processing to request a reopening. (You can use the claim status feature to determine the status of the claim preventing you from requesting the reopening.)

Due to complex nature of the requested change this request cannot be handled as a reopening. Please submit redetermination request.
Cause: A claim adjustment that requires Medicare to review documentation is not considered a minor error or omission. Adjustments involving modifiers 22, 23, 53, 55 62, 66, 74, and CR require Medicare to review documentation and are therefore too complex to process as a clerical error reopening. You will need to resubmit a redetermination request with the appropriate documentation.

Due to the complex nature of this claim, you must submit a redetermination request.
Cause: The claim is for a CPT procedure code ending with a “99” (e.g., 01999, 33999, 99499, etc.). These codes are generally “not otherwise classified” (NOC) or unlisted procedure codes. Since Medicare needs to review documentation to determine the procedure performed, as well as determine Medicare’s coverage and payment, adjustments to these codes cannot be done as a reopening.