CMS Pub. 100-04, ch. 34, § 10.6.2

A party may request a contractor reopen and revise its initial determination or

redetermination under the following conditions:

• Within 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 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.

While a contractor can reopen 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 functions (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 similar fault.