---
kind: "section"
citation: "42 C.F.R. § 478.48"
title: "42"
number: "478.48"
heading: "Reopening and revision of a reconsidered determination or a decision."
url: "https://uscodex.org/cfr/42/478.48"
---

# §478.48. Reopening and revision of a reconsidered determination or a 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 [§ 478.15](/cfr/42/478.15.md), 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](/cfr/42/478.15.md), 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](/cfr/42/405.980.md) of this chapter, which concerns reopenings and revised decisions under [subpart I of part 405](/cfr/42/part405-subpartI.md) 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.

## Notes

### Amendments

[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; 77 FR 68563, Nov. 15, 2012; 82 FR 5140, Jan. 17, 2017]

### Source

Source: 50 FR 15372, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.

### Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

### Amendments

[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; 77 FR 68563, Nov. 15, 2012; 82 FR 5140, Jan. 17, 2017]