---
kind: "range"
citation: "42 C.F.R. §§ 405.980–405.986"
title: "42"
from: "405.980"
to: "405.986"
count: 4
url: "https://uscodex.org/cfr/42/405.980..405.986"
---

# §405.980. Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.

- (a) **General rules.**
  - (1) A reopening is a remedial action taken to change a binding determination or decision that resulted in either an overpayment or underpayment, even though the binding determination or decision may have been correct at the time it was made based on the evidence of record. That action may be taken by—
    - (i) A contractor to revise the initial determination or redetermination;
    - (ii) A QIC to revise the reconsideration;
    - (iii) An ALJ or attorney adjudicator to revise his or her decision; or
    - (iv) **The Council to revise the ALJ or attorney adjudicator decision, or its review decision.**
  - (2) If a contractor issues a denial of a claim because it did not receive requested documentation during medical review and the party subsequently requests a redetermination, the contractor must process the request as a reopening.
  - (3) Notwithstanding [paragraph (a)(4)](#a-4) of this section, a contractor must process clerical errors (which includes minor errors and omissions) as reopenings, instead of as redeterminations as specified in [§ 405.940](/cfr/42/405.940.md). If the contractor receives a request for reopening and disagrees that the issue is a clerical error, the contractor must dismiss the reopening request and advise the party of any appeal rights, provided the timeframe to request an appeal on the original denial has not expired. For purposes of this section, clerical error includes human or mechanical errors on the part of the party or the contractor such as—
    - (i) Mathematical or computational mistakes;
    - (ii) Inaccurate data entry; or
    - (iii) **Denials of claims as duplicates.**
  - (4) When a party has filed a valid request for an appeal of an initial determination, redetermination, reconsideration, ALJ or attorney adjudicator decision, or Council review, no adjudicator has jurisdiction to reopen an issue on a claim that is under appeal until all appeal rights for that issue are exhausted. Once the appeal rights for the issue have been exhausted, the contractor, QIC, ALJ or attorney adjudicator, or Council may reopen as set forth in this section.
  - (5) The contractor's, QIC's, ALJ's or attorney adjudicator's, or Council's decision on whether to reopen is binding and not subject to appeal.
  - (6) A determination under the Medicare secondary payer provisions of section 1862(b) of the Act that Medicare has an MSP recovery claim for services or items that were already reimbursed by the Medicare program is not a reopening, except where the recovery claim is based upon a provider's or supplier's failure to demonstrate that it filed a proper claim as defined in [part 411](/cfr/42/part411.md) of this chapter.
- (b) **Time frames and requirements for reopening initial determinations and redeterminations initiated by a contractor.** A contractor may reopen an initial determination or redetermination on its own motion—
  - (1) **Within 1 year from the date of the initial determination or redetermination for any reason.**
  - (2) Within 4 years from the date of the initial determination or redetermination for good cause as defined in [§ 405.986](/cfr/42/405.986.md).
  - (3) At any time if there exists reliable evidence as defined in [§ 405.902](/cfr/42/405.902.md) that the initial determination was procured by fraud or similar fault as defined in [§ 405.902](/cfr/42/405.902.md).
  - (4) At anytime 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.
  - (5) **At any time to effectuate a decision issued under the coverage appeals process.**
- (c) **Time frame and requirements for reopening initial determinations and redeterminations requested by a party.**
  - (1) A party may request that a contractor reopen its initial determination or redetermination within 1 year from the date of the initial determination or redetermination for any reason.
  - (2) A party may request that a contractor reopen its initial determination or redetermination within 4 years from the date of the initial determination or redetermination for good cause in accordance with [§ 405.986](/cfr/42/405.986.md).
  - (3) A party may request that a contractor reopen its initial determination 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. See [§ 405.986(c)](/cfr/42/405.986.md?p=c).
  - (4) A party may request that a contractor reopen an initial determination for the purpose of reporting and returning an overpayment under [§ 401.305](/cfr/42/401.305.md) of this chapter.
- (d) **Time frame and requirements for reopening reconsiderations, decisions and reviews initiated by a QIC, ALJ or attorney adjudicator, or the Council.**
  - (1) A QIC may reopen its reconsideration on its own motion within 180 calendar days from the date of the reconsideration for good cause in accordance with [§ 405.986](/cfr/42/405.986.md). If the QIC's reconsideration was procured by fraud or similar fault, then the QIC may reopen at any time.
  - (2) An ALJ or attorney adjudicator may reopen his or her decision, or the Council may reopen an ALJ or attorney adjudicator decision on its own motion within 180 calendar days from the date of the decision for good cause in accordance with [§ 405.986](/cfr/42/405.986.md). If the decision was procured by fraud or similar fault, then the ALJ or attorney adjudicator may reopen his or her decision, or the Council may reopen an ALJ or attorney adjudicator decision, at any time.
  - (3) The Council may reopen its review decision on its own motion within 180 calendar days from the date of the review decision for good cause in accordance with [§ 405.986](/cfr/42/405.986.md). If the Council's decision was procured by fraud or similar fault, then the Council may reopen at any time.
- (e) **Time frames and requirements for reopening reconsiderations, decisions, and reviews requested by a party.**
  - (1) A party to a reconsideration may request that a QIC reopen its reconsideration within 180 calendar days from the date of the reconsideration for good cause in accordance with [§ 405.986](/cfr/42/405.986.md).
  - (2) A party to an ALJ or attorney adjudicator decision may request that an ALJ or attorney adjudicator reopen his or her decision, or the Council reopen an ALJ or attorney adjudicator decision, within 180 calendar days from the date of the decision for good cause in accordance with [§ 405.986](/cfr/42/405.986.md).
  - (3) A party to a Council review may request that the Council reopen its decision within 180 calendar days from the date of the review decision for good cause in accordance with [§ 405.986](/cfr/42/405.986.md).

# §405.982. Notice of a revised determination or decision.

- (a) **When adjudicators initiate reopenings.** When any determination or decision is reopened and revised as provided in [§ 405.980](/cfr/42/405.980.md), the contractor, QIC, ALJ or attorney adjudicator, or the Council must mail its revised determination or decision to the parties to that determination or decision at their last known address. In the case of a full or partial reversal resulting in issuance of a payment to a provider or supplier, a revised electronic or paper remittance advice notice must be issued by the Medicare contractor. An adverse revised determination or decision must state the rationale and basis for the reopening and revision and any right to appeal.
- (b) **Reopenings initiated at the request of a party.** The contractor, QIC, ALJ or attorney adjudicator, or the Council must mail its revised determination or decision to the parties to that determination or decision at their last known address. In the case of a full or partial reversal resulting in issuance of a payment to a provider or supplier, a revised electronic or paper remittance advice notice must be issued by the Medicare contractor. An adverse revised determination or decision must state the rationale and basis for the reopening and revision and any right to appeal.

# §405.984. Effect of a revised determination or decision.

- (a) **Initial determinations.** The revision of an initial determination is binding upon all parties unless a party files a written request for a redetermination that is accepted and processed in accordance with [§ 405.940](/cfr/42/405.940.md) through [§ 405.958](/cfr/42/405.958.md).
- (b) **Redeterminations.** The revision of a redetermination is binding upon all parties unless a party files a written request for a QIC reconsideration that is accepted and processed in accordance with [§ 405.960](/cfr/42/405.960.md) through [§ 405.978](/cfr/42/405.978.md).
- (c) **Reconsiderations.** The revision of a reconsideration is binding upon all parties unless a party files a written request for an ALJ hearing that is accepted and processed in accordance with [§ 405.1000](/cfr/42/405.1000.md) through [§ 405.1063](/cfr/42/405.1063.md).
- (d) **ALJ or attorney adjudicator decisions.** The revision of an ALJ or attorney adjudicator decision is binding upon all parties unless a party files a written request for a Council review that is accepted and processed in accordance with [§ 405.1100](/cfr/42/405.1100.md) through [§ 405.1130](/cfr/42/405.1130.md).
- (e) **Council review.** The revision of a Council review is binding upon all parties unless a party files a civil action in which a Federal district court accepts jurisdiction and issues a decision.
- (f) **Appeal of only the portion of the determination or decision revised by the reopening.** Only the portion of the initial determination, redetermination, reconsideration, or hearing decision revised by the reopening may be subsequently appealed.
- (g) **Effect of a revised determination or decision.** A revised determination or decision is binding unless it is appealed or otherwise reopened.

# §405.986. Good cause for reopening.

- (a) **Establishing good cause for reopening.** Good cause may be established when—
  - (1) **There is new and material evidence that—**
    - (i) Was not available or known at the time of the determination or decision; and
    - (ii) May result in a different conclusion; or
  - (2) 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.
- (b) **Change in substantive law or interpretative policy.** A change of legal interpretation or policy by CMS in a regulation, CMS ruling, or CMS general instruction, or a change in legal interpretation or policy by SSA in a regulation, SSA ruling, or SSA general instruction in entitlement appeals, whether made in response to judicial precedent or otherwise, is not a basis for reopening a determination or hearing decision under this section. This provision does not preclude contractors from conducting reopenings to effectuate coverage decisions issued under the authority granted by [section 1869(f)](/cfr/42/1869.md?p=f) of the Act.
- (c) **Third party payer error.** A request to reopen a claim based upon a third party payer's error in making a primary payment determination when Medicare processed the claim in accordance with the information in its system of records or on the claim form does not constitute good cause for reopening.