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42 C.F.R. § 478.48   Reopening and revision of a reconsidered determination or a hearing decision.

Title 42 - Public Health

Title 42: Public Health
PART 478—RECONSIDERATIONS AND APPEALS
Subpart B—Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals

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§ 478.48   Reopening and revision of a reconsidered determination or a hearing decision.

(a) QIO reopenings—(1) General rule. A QIO or QIO subcontractor that made a reconsidered determination, or conducted a review of a DRG change as described in §473.15, that is otherwise binding, may reopen and revise the reconsidered determination or review, either on its own motion or at the request of a party, within one year from the date of the reconsidered determination or review.

(2) Extension of time limit. A QIO or QIO subcontractor may reopen and revise its reconsidered determination, or its review of a DRG change as described in §473.15, that is otherwise binding, after one year but within four years of the date of the determination or review if—

(i) The QIO receives new material evidence;

(ii) The QIO erred in interpretation or application of Medicare coverage policy;

(iii) There is an error apparent on the face of the evidence upon which the reconsidered determination was based; or

(iv) There is a clerical error in the statement of the reconsidered determination.

(b) ALJ and Departmental Appeals Board Reopening—Applicable procedures. The ALJ or the Departmental Appeals Board, whichever made the decision, may reopen and revise the decision in accordance with the procedures set forth in §405.750(b) of this chapter, which concerns reopenings and revisions under subpart G of part 405 of this chapter.

(c) Fraud or similar abusive practice. A reconsidered determination, a review of a DRG change, or a decision of an ALJ or the Departmental Appeals Board may be reopened and revised at any time, if the reconsidered determination, review, or decision was obtained through fraud or a similar abusive practice that does not support a formal finding of fraud.

[50 FR 15372, Apr. 17, 1985, as amended at 61 FR 32349, June 24, 1996; 62 FR 25855, May 12, 1997. Redesignated at 64 FR 66279, Nov. 24, 1999]

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