CMS Pub. 100-06, ch. 8, § 100

Instructions that describe the circumstances under which the final determination on a cost

report can be reopened are contained in 42 CFR 405.1885 and PRM-1, Sections 2931

through 2932. In accordance with these instructions, you may reopen a cost report if you

receive a written request to reopen from the provider within 3 years of the date that the

Notice of Amount of Program Reimbursement (NPR) was issued. You may also reopen

a cost report within the 3-year reopening period based on your own motion or at the

request of CMS. However, if fraud or similar fault is involved, you can reopen the cost

report at any time.

If a provider submits a written reopening request to you before the 3-year reopening

period expires, you must apply the provisions of PRM-1, §2931.2 when making a

decision whether the provider’s request warrants a reopening. You must issue a

reopening notice or a denial of reopening to the provider in writing.

A single letter may be used as a notice of reopening of some issues and a denial of other

issues. However, ensure that all issues that you intend to reopen are listed in the written

reopening notice. Where you deny the provider’s reopening request, include in the

written notification to the provider detailed reasons for the rejection. Such reasons could

include:

y Untimely request, with an indication of the dates and documents being used in the

determination.

y Incomplete request, with an explanation of why it was determined to be

incomplete.

y Criteria for reopening not met, with an explanation of why the criteria were not

met.

Where you grant a provider’s reopening request and discover that additional information

is still needed, whether before or after the 3-year reopening period expires, send a written

notice to the provider requesting that the needed information be submitted within a

specified time. In normal circumstances the provider should submit the documentation

within 60 days of your request. If the provider fails to submit the requested information,

you may withdraw the notice of reopening and deny the reopening.

You must also send the provider a written reopening notice detailing the issues when

reopening the cost report on your own motion or at CMS’ request. If you reopen the cost

report and plan to resolve the issues without a field audit but need additional information,

send a written notice to the provider requesting that the needed information be submitted

within a specified time (generally within 60 days of the request). If the provider fails to

submit the requested information, adjust the cost report accordingly. If you determine

that a field audit is necessary to resolve the reopening issues, follow the instructions in

§§60.1, 60.10, 60.11, and 60.12 pertaining to information requests.

Whenever you issue a NPR for a provider that is part of a chain before the home office

cost statement is finalized, include a reopening letter with the NPR specifying that the

amount of program reimbursement may be changed upon receipt of finalized home office

cost statement. However, do not issue such a reopening notice to a provider that is paid

entirely under PPS or if the amount of home office cost claimed in the cost report is

immaterial. When the home office cost statement is finalized, close the reopening by

issuing either a revised NPR or a notice that the reopening is being closed.

If issues outside the scope of the reopening notice are discovered during the course of the

reopening process and reaudit, you may address such issues only if the provider submits

another reopening request before the expiration of the 3-year reopening period or you

issue another notice of reopening within the 3-year reopening period.

Issue a revised NPR for all reopened cost reports within 180 days of receipt of all

information/documentation necessary to resolve the reopening issues. Discuss with the

RO any situations where unforeseen circumstances prevent you from meeting these

expectations.

Furthermore, you are required to submit HCRIS extracts to CMS each and every time

that you issue a revised NPR following a reopening of a cost report. These submissions

are due within 30 days after the issuance of the revised NPR. (See §§10.4 and 90.1 for

details of the type of facility cost reports that are to be submitted.)