Section 937 of the Medicare Modernization Act (MMA) directs the Secretary to develop, in consultation with Medicare contractors and representatives of providers and suppliers, a process to allow the correction of minor errors or omissions without the need to initiate an appeal. The deadline for implementing this provision was set at one year after enactment of the MMA, i.e., December 8, 2004. In response, CMS did not develop any new process, but rather issued a statement outlining current processes which it asserts adequately provide for correcting minor errors and omissions without the need for appeal. This statement can be found at www.cms.hhs.gov/medlearn/matters/
mmarticles/2004/SE0420.pdf.

CMS describes four processes. The first is the correction of incomplete or invalid claim submissions. Applicable procedures are outlined in the Medicare Claims Processing Manual at section 80.3.2 (Handling Incomplete or Invalid Claims) and section 70.2.3.1 (Incomplete or Invalid Submissions). Incomplete submissions are those missing required information; invalid submissions contain complete information but the information is illogical or incorrect. Claims with missing or incorrect information for certain specified items are considered unprocessable and "returned' to the provider. Such claims may actually be returned to the provider for correction and resubmission, or may be held with the request that the provider supply the corrected or missing information. No appeal is required under these processes to correct information necessary to process the claim.

The second mechanism discussed by CMS is the correction of mistakes in previously processed claims, known as the adjustment request process. This process is required when bills have been accepted and posted in error to a particular record. Further information is set forth in the Medical Claims Processing Manual, chapter 3, section 50.

A reopening can provide relief without the need for an appeal. Reopenings are permitted pursuant to the statute and regulations, and discussed in the Medicare Claims Processing Manual at chapter 29, section 60.27. However, providers should note that reopenings are at the sole discretion of the intermediary or carrier. Thus, a provider that wants to preserve its rights to have the issues heard by a higher authority should file a formal appeal. Generally, there is a one-year window for requesting a reopening of a carrier initial determination and a three-year window for requesting a reopening of an intermediary determination. Although the CMS instructions assert that adjustments to claims arising from clerical errors must be handled through the reopening process, such errors may be pursued through the appeal process.

The fourth and final mechanism discussed by CMS involves correction of compliance issues related to HIPAA matters. Where there is an evaluation of a claim's compliance with HIPAA, the process established is set forth in the Medicare Claims Processing Manual, chapter 24, sections 30.6, 70.1, and 70.2.