(Medicare Claims Processing Manual)

 Within 1 year from the date of the initial determination or redetermination for any reason; or    Within 4 yea rs from the date of the initial determination or redetermination for good cause as defined in 10.11; or    At any time if:   o There exists reliable evidence that the initial determination was procured by fraud or similar fault as defined in 42 CFR 405.902 ; or  o 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.  Third party payer error does not constitute clerical error as defined in 10.4; or,   At any time to effectuate a coverage decision issued under 42 CFR 426.460(b)(1)(i) , 426.488(b) and (c)  or 426.560 (b)(1)(i)  appeals process.   10.6.2 - Timeframes for Party Requested Reopenings  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A party may request a contractor reopen and revise its initial determination or redetermination under the following conditions:    With in 1 year from the date of the initial determination or redetermination for any reason; or    Within 4 years from the date of the initial determination or redetermination for good cause as defined in 10.11; or,   At any time if the initial determination is u nfavorable, 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.  Third party payer error does not constitute clerical error as defined in 10.4.  While a contractor can r eopen at any time under the limited criterion set forth above to correct an unfavorable determination, CMS does not expect that a contractor would regularly grant these requests, especially for older claims where the claims history is not readily available.  Both the contractor and the provider/physician/supplier have a reasonable expectation to administrative finality in the processing of their claims.  Additionally, administrative efficiency and the ability of a Medicare contractor to continue vital funct ions (i.e., process Medicare claims and process appeal requests) require that contractors grant such requests rarely.   10.6.3 - Timeframes for Adjudicator to Reopen  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)A   QIC, ALJ or  the AC may reopen and revise its reconsideration, hearing decision or review, respectively, under the following conditions:    Within 180 days from the date of its decision for good cause in accordance with 42 CFR 405.986 ; or,    At any time if the reconsideration, hearing decision or review was procured by fraud or simi lar fault.   10.6.4 - Timeframes When a Party Requests an Adjudicator Reopen Their Decisions  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A party may request a QIC, ALJ or the AC reopen and revise its reconsideration, hearin g decision or review within 180 days from the date of the reconsideration, hearing decision or review, as applicable, for good cause in accordance with 42 CFR 405.986 .  10.7 - Timeframes to Complete a Reopening Requested by a Party  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)  There are no timeframes established in statute or regulati on governing the timeframes for a contractor to complete a reopening action.  However, a party to an initial determination has a reasonable expectation to the administrative finality of a determination issued by Medicare.  Therefore, this section sets out timeframes to complete the reopening action once the reopening has been initiated.  These timeframes apply only to those reopening requests that are requested by the party to the initial determination.  These timeframes do not apply to contractor initiated  reopenings.   For those reopenings requested by a party that the contractor agrees to reopen, the contractor shall complete the reopening action 60 days from the date of receipt of the partys reopening request in the corporate mailroom, receipt in a secur e Internet portal/application,  or receipt of the telephone request.  This does not apply to big box cases defined as aggregated requests filed by a provider, physician, or other supplier that involve 40 or more beneficiaries/claims and $40,000 or more i n controversy.   10.8 - Notice of a Revised Determination or Decision  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)  If the reopening action results in a revised determination or decision that results in payment to a provider, physician, or supplier, a revised electronic or paper remittance advice notice must be issued by the Medicare contractor and will satisfy the notice requirements.  If applicable, a revised Medicare Summary Notice will suffice for notice to the beneficiary  in the above instances.  If the reopening action results in an adverse revised determination or decision the contractor shall mail, or if approved by CMS, transmit via a secure Internet portal/application a letter that states the rationale and basis for the reopening and revision and any right to appeal.  The timeframe to request the appeal would be based on the date of the contractors revised determination.  If the contractor cannot change the original determination or chooses to not accept the request, the contractor should inform the requestor that the contractor cannot process their reopening request.  If the request is over the telephone, the contractor can verbally inform the caller that they cannot process their request.  If it is a written reopenin g request submitted via hard copy or a secure Internet portal/application, the contractor shall send a brief letter via mail or, if approved by CMS, a secure Internet portal/application, informing the requestor that they cannot process the request.  The contractor should state that their decision to not reopen a claim determination is not an initial determination and is therefore not appealable.   10.9 - Revised Determination or Decision  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  A revised determination or decision is one in which:    The end result is changed (e.g., a service previously found to be covered is now found not to be covered or the allowable charge for the service is determined to be incorrect); or    The end r esult is not changed, but a party might be disadvantaged by the revision (e.g., a request for payment on a claim previously disallowed because the services were not medically necessary and therefore subject to the limitation on liability provisions, is now to be disallowed on a basis that precludes consideration of limitation on liability).   10.10 - Effect of a Revised Determination or Decision  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  The revision of an initial determina tion is binding on all parties unless a party files a written request for a redetermination of the revised determination that is accepted and processed.  The request for a redetermination must be filed within 120 days from the date of the revised initial d etermination.  The revision of a redetermination is binding on all parties unless a party files a written request for a QIC reconsideration that is accepted and processed.   10.11 - Good Cause for Reopening (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09 -30-16)  On its own initiative or at the request of party (see IOM Pub. 100- 04, chapter 29, 110 for the definition of a party), a contractor may reopen an initial determination or redetermination within 4 years  from the date of the initial determination  or redetermination  when good cause exists.  However, good cause is not required for reopening of claims for up to 1 year from the date of the initial determination or redetermination.  Under 42 CFR 405.986 , good cause exists when:    There is new and material evidence that was not available or known at the time of the determination or decision and may result in a different conclusion; or    The evidence that was considered in making the determination or decision clearly shows on its face that an obvious error was made at the time of the determination or decision.  A contractors decision to reopen based on the existence of good cause, or refusal to reopen after determining good cause does not exist, is not subject to appeal.  See 42 CFR 405.926(l) , and 405.980(a)(5) .  NOTE:   Third par ty payer error in making a primary payment determination does not constitute good cause for the purposes of reopening an initial determination or redetermination when Medicare processed the claim in accordance with the information in its system of records or on the claim form.  Contractors may only reopen for third party payer error under the within one year for any reason standard.  This is true for both contractor initiated reopenings as well as reopenings requested by a party.  All providers and suppli ers have a legal obligation to determine the correct primary payer when billing Medicare.  Failure to do so, regardless of third party payer error, does not constitute good cause that will permit reopening beyond one year.  Information regarding such error does not constitute new and material evidence.   10.11.1 - What Constitutes New and Material Evidence  (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  New and material evidence is one of the means for establishing good cause to  reopen an initial determination or redetermination.  New and material evidence is evidence that:   1. Was not readily available or known to the person or entity requesting/initiating the reopening at the time of the initial determination or redetermination ; and   2. May result in a conclusion different from that reached in the initial determination or redetermination.  For example, data analysis that identifies a high error rate or pattern of potential overutilization on the part of a provider or supplier is one example of evidence that is not readily available or known to a contractor at the time it made its initial determination, and may cause the contractor to believe its initial determinations for the claims of the provider or supplier were incorrect.  Evidence may include any record used in the provision of medical care that supports whether or not the service was covered, medically necessary, and provided as billed.  This includes medical records, progress notes, orders, procedure reports, invoices, pr oofs of delivery, or other documentation as required by CMS policy.  However, as explained further below, any such evidence submitted by a party must satisfy the good cause standard set forth in 405.986 (i.e., that it is new and material evidence (as desc ribed above), or demonstrates that the evidence considered in making the initial determination or redetermination clearly shows on its face that an obvious error was made at the time of the determination or decision).  10.11.2 - Policies Related to Good Cause Reopenings for New and Material Evidence  (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  In determining whether good cause exists for reopening an initial determination or redetermination, the contractor considers whether evidence is new and material from the perspective of the person or entity requesting or initiating the reopening.   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.