---
kind: "section"
citation: "42 C.F.R. § 405.986"
title: "42"
number: "405.986"
heading: "Good cause for reopening."
url: "https://uscodex.org/cfr/42/405.986"
---

# §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.

## Notes

### Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37703, June 30, 2005; 86 FR 65660, Nov. 19, 2021]

### Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

### Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37703, June 30, 2005; 86 FR 65660, Nov. 19, 2021]