A reopening. The regulation, 42 CFR 405.980, says "a contractor must process clerical errors (which includes minor errors and omissions) as reopenings, instead of as redeterminations". Its examples include "Mathematical or computational mistakes," "Inaccurate data entry," and "Denials of claims as duplicates." Remember one thing from the start: a reopening request and an appeal deadline are separate clocks. Keep the appeal deadline on the calendar.
The rule, in the regulation's words
42 CFR 405.980(a)(3): "a contractor must process clerical errors (which includes minor errors and omissions) as reopenings, instead of as redeterminations"
So the regulation sends clerical problems down the reopening route instead of the redetermination route.
What counts as a clerical error
The regulation gives examples:
- "Mathematical or computational mistakes"
- "Inaccurate data entry"
- "Denials of claims as duplicates"
It also draws a line:
42 CFR 405.980(c)(3): "Third party payer error does not constitute clerical error."
When a reopening can be requested
The regulation sets out two windows for a party's request:
42 CFR 405.980(c)(1): "within 1 year from the date of the initial determination or redetermination for any reason."
42 CFR 405.980(c)(3): "at any time if the initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based."
Note the limit on the second window: it's "only for the purpose of correcting a clerical error."
If the contractor doesn't agree it's clerical
The regulation covers that case too. If the contractor disagrees that the issue is a clerical error, it:
"must dismiss the reopening request and advise the party of any appeal rights, provided the timeframe to request an appeal on the original denial has not expired." (42 CFR 405.980(a)(3))
Read the end of that sentence closely: "provided the timeframe to request an appeal on the original denial has not expired."
Two separate clocks
Build your process around this:
A reopening request and an appeal deadline are separate clocks. Keep the appeal deadline on the calendar.
And on the reopening decision itself:
42 CFR 405.980(a)(5): the decision on whether to reopen "is binding and not subject to appeal."
A desk habit before you send anything
These are practical suggestions, not regulatory text:
- Is it a clerical error (math, data entry, a duplicate denial)? Then it's a reopening, per your MAC's reopening instructions.
- Not clerical, or not sure? Read the denial and the appeal instructions.
- Either way, keep the appeal deadline on the calendar. It's a separate clock.
When in doubt, check the source and your MAC.
FAQ
Are clerical errors on Medicare claims handled as reopenings or appeals?
42 CFR 405.980(a)(3): "a contractor must process clerical errors (which includes minor errors and omissions) as reopenings, instead of as redeterminations".
What counts as a clerical error?
The regulation's examples are "Mathematical or computational mistakes," "Inaccurate data entry," and "Denials of claims as duplicates." It also says, "Third party payer error does not constitute clerical error."
How long do I have to request a reopening?
Under 42 CFR 405.980(c), a reopening may be requested "within 1 year from the date of the initial determination or redetermination for any reason," or "at any time if the initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based."
How should I think about a reopening request and an appeal deadline?
A reopening request and an appeal deadline are separate clocks. Keep the appeal deadline on the calendar.
Related resources
- How to define a denial queue before asking for outside help
- How to start with one focused aging A/R project
Know what's moving, what's stuck, what happens next. Start with one queue.
This page is run by RxRev.
Source: 42 CFR 405.980, Reopening of initial determinations, redeterminations, reconsiderations, hearings and reviews (current eCFR). All quotes above are from this section.