CMS Pub. 100-04, ch. 34, § 10.11

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 contractor’s 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 party 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 suppliers 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.”