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Code of Federal Regulations Title 42. Public Health § 42.478.48 Reopening and revision of a reconsidered determination or a decision

Current as of January 02, 2025 | Updated by Findlaw Staff

(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 § 478.15, 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 § 478.15, 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 or attorney adjudicator and Council Reopening—Applicable procedures. The ALJ or attorney adjudicator, or the Council, whichever made the decision, may reopen and revise the decision in accordance with the procedures set forth in § 405.980 of this chapter, which concerns reopenings and revised decisions under subpart I 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 attorney adjudicator, or the Council 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.

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.478.48 Reopening and revision of a reconsidered determination or a decision - last updated January 02, 2025 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-478-48/

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