(Medicare Claims Processing Manual)

When a party requests a reopening of an initial determination or redetermination for good cause based on the submission of new and material e vidence, the following policies apply:    The mere submission of additional evidence is not necessarily sufficient to establish good cause to reopen an initial determination or decision.  The information must be new, (i.e., not readily available or known t o exist at the time of the initial determination) as well as material (i.e., may result in a different conclusion).  A party should explain how the information constitutes new and material evidence that establishes good cause.  If the contractor is unable to determine whether the information submitted with a reopening request constitutes new and material evidence, the contractor may decide not to grant the reopening.    When a request for reopening is submitted with new and material evidence, but additional i nformation or evidence is needed before a proper revised determination or decision can be made, the contractor may contact the party seeking the reopening, and request that they obtain and submit the additional information.  If the person or entity request ing the reopening cannot obtain the additional information, the Medicare contractor assists to the extent that it is reasonably able to do so.  When a Medicare contractor initiates a reopening of an initial determination or redetermination for good cause based on the existence of new and material evidence, the following policies apply:    The contractor is responsible for clearly documenting in the case file the new and material evidence that represents good cause for reopening.    In order to promote administrative efficiency, Medicare does not generally require that a party submit supporting medical documentation with the initial claim.  Therefore, if a medical record or other supporting documentation was not utilized when a contractor made an initial determination, because it was not requested or was not provided, then the content of any medical records or supporting documentation which are subsequently requested by the contractor during the course of its review would constitute new evidence.   10.11.3 - What Constitutes Error on the Face of the Evidence (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  Error on the face of the evidence exists if it is clear that the determination or decision was incorrect based on all evidence i n file on which the determination or decision was based, or any evidence of record anywhere in the contractors Medicare file or in CMS files at the time such determination or decision was made.   10.12 - Change in Substantive Law or Interpretative Policy  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A change of legal interpretation or policy by CMS in a regulation, CMS ruling or CMS general instruction, or a change in legal interpretation or policy by SSA in a regulation, SSA ruling or SSA general instruction in entitlement appeals, whether made in response to judicial precedent or otherwise, is not a basis for reopening a determination or decision under this section.  This provision does not preclude contractors from conducti ng reopenings to effectuate coverage decisions issued under 42 CFR 42 CFR 426.460(b)(1)(i) , 426.488 (b) and (c) , or 426.560(b)(1)(i)  appeals process..  10.13  System and Processing Requirements for Use of Secure Internet Portal/Application to Support Reopening Activities (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10 -03-11)  Contractors who develop and utilize a secure Internet portal/application for reopening purposes shall ensure, at a minimum:    CMS approves (i.e., Contract Manager or Project Officer, if applicable, and Appeals Business Function Lead) the proposed portal/application and usage prior to development and implementation.   The portal/application fully complies and has been tested to ensure compliance with all CMS system security requirements regarding protected health information prior to implementation/usage.    The secure Internet portal/application includes a formal registration process that validates the signature.  This process shall include, at a minimum, use of restricted user identifiers (IDs) and passwords. Contractors shall include an indication and/or description of the validation methodology in the appeals case file should an appeal on the item/service reopened be requested.    Templates for submission of electronic reopening request shall include, at a minimum, a method for authe nticating that the party has completed the portal/application registration process and has been properly identified by the system as an appropriate user.    Contractors utilizing an approved portal/application shall provide education to parties to the reopen ing regarding system capabilities/limitations prior to implementation and utilization of the secure portal/application.    Contractors shall also educate parties to the reopening that participation/enrollment in the secure portal/application is at the discre tion of the party and the party bears the responsibility for the authenticity of the information being attested to.    Appropriate procedures are in place to provide parties with confirmation of receipt of the reopening request via secure Internet/portal and  verbiage instructing the parties not to submit additional reopening requests for the same item or service via different venue (hard copy mail or telephone).    Contractors utilizing a secure portal/application shall ensure that there is a process in place b y which a party can submit additional documentation/materials concurrent with the reopening request.  The portal/application shall have the capability to accept additional documentation and/or other materials to support reopening requests.   Refusal to reop en and adverse revised determination notices transmitted via a secure Internet portal/application shall comply with the timeliness and content requirements as outlined in the Pub. 100- 04, chapter 34.  In addition, contractors shall provide hard copy decisi on notices to parties to the reopening, as required, who do not have access to the secure Internet portal/application.  The notices must be mailed and/or otherwise transmitted concurrently (i.e., mailed on the same day the notice is transmitted via the sec ure portal/application).   Contractors utilizing a secure Internet portal/application shall include the adverse revised determination/decision notice and any other related materials in the appeals case file if a valid appeal on the item/service is later req uested.    Contractors shall also ensure that parties may save and print the revised adverse determination/decision notice or refusal to reopen notice and that the secure portal/application includes a mechanism by which the date/time of the notification is tracked/marked both in the system and on any printed decision notices so as to adequately inform the party of timeframes for ensuring timely submission of future appeal requests.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R4219CP  01/25/2019  Update to Pub. 100- 04 Chapter 34 to Provide Language -Only Changes for the New Medicare Card Project  02/26/2019  11115  R3568CP  07/29/2016  Reopenings Update -  Changes to Chapter 34  09/30/2016  9639 R2241CP  06/17/2011  Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Reopenings Via a Secure Internet Portal/Application  10/03/2011  7420 R1671CP  01/16/2009  Clarification of Requirements for New and Material Evidence as Good Cause for Reopening 02/16/2009  6157 R1069CP  09/29/2006  Initial Release of Chapter -Reopenings and Revisions of Claim Determinations and Decisions  11/29/2006  4147 Back to top of chapter