100-04 Medicare Claims Processing Manual: Chapter 34 - Reopening and Revision of Claim Determinations and Decisions

Medicare Claims Processing Manual
Chapter 34 - Reopening and Revision of Claim
Determinations and Decisions
(Rev. 4219, 01-25-19)
Table of Contents
Transmittals for Chapter 34
10 - Reopenings and Revisions of Claim Determinations and Decisions - General
10.1 - Authority to Conduct a Reopening
10.2 - Refusal to Reopen is Not an Initial Determination
10.3 - Reopening of Denials Based on an Unanswered ADR Request
10.4 - Reopenings Based on Clerical or Minor Errors and Omissions
10.4.1 - Providers Submitting Adjustments
10.5 - Telephone Reopenings – Required for A/B MACs (B) Only
10.5.1 - Informing the Provider Communities About the Telephone
Reopenings Process
10.5.2 - Issues for Telephone Reopenings
10.5.3 - Conducting the Telephone Reopening
10.5.4 - Documenting the Telephone Reopening
10.5.5 – Monitoring the Telephone Reopening
10.6 - Timeframes to Reopen Claim Determinations
10.6.1 - Timeframes for Contractor Initiated Reopenings
10.6.2 - Timeframes for Party Requested Reopenings
10.6.3 - Timeframes for Adjudicator to Reopen
10.6.4 - Timeframes When a Party Requests an Adjudicator Reopen Their
Decision
10.7 - Timeframes to Complete a Reopening Request by a Party
10.8 - Notice of a Revised Determination or Decision
10.9 - Revised Determination or Decision
10.10 - Effect of a Revised Determination or Decision
10.11 - Good Cause for Reopening

10.11.1 - What Constitutes New and Material Evidence
10.11.2 – Policies Related to Good Cause Reopenings for New and
Material Evidence
10.11.3 – What Constitutes Error on the Face of the Evidence
10.12 - Change in Substantive Law or Interpretative Policy
10.13 – System and Processing Requirements for Use of Secure Internet
Portal/Application to Support Reopening Activities

10 - Reopenings and Revisions of Claims Determinations and Decisions -
General
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
A reopening is a remedial action taken to change a binding determination or decision that
resulted in either an overpayment or an underpayment, even though the determination or
decision was correct based on the evidence of record. Reopenings are separate and
distinct from the appeals process. Reopenings are a discretionary action on the part of the
contractor. A contractor’s decision to reopen a claim determination is not an initial
determination and is therefore not appealable. Requesting a reopening does not toll the
timeframe to request an appeal. If the reopening action results in a revised determination,
then new appeal rights would be offered on that revised determination. Under certain
circumstances a party may request a reopening even if the timeframe to request an appeal
has not expired.
Historically, contractors have employed a variety of informal procedures under the
general heading of “reopenings,” “re-reviews,” “informal redeterminations,” etc.
Providers, physicians and suppliers may have come to view these as appeal rights.
However, as stated above, reopenings are separate and distinct from the appeals process.
They are not a party’s right. Contractors shall not use them to provide an appeal when a
formal appeal is not available. Contractors should also note that while clerical errors
must be processed as reopenings, all decisions on granting reopenings are at the
discretion of the contractor.
Contractors may conduct a reopening to revise an initial determination or
redetermination. Medicare Secondary Payer (MSP) recovery claims where the debtor is
the beneficiary or provider/supplier are not reopening actions except where the recovery
claim is a MSP provider/supplier recovery claim because the provider/supplier failed to
file a proper claim as defined in 42 CFR Part 411. Aside from this one exception, MSP
recovery claims involve recovery of the insurance funds at issue, not recovery of the
payment previously made by Medicare. Consequently, the recovery action does not
involve the reopening of Medicare's payment determination. The MSP recovery demand
letter is an "initial determination" as defined in 42 CFR 405.924, not a reopening and
revision of Medicare's initial claims payment determination.
10.1 - Authority to Conduct a Reopening
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
Reopenings can be conducted by a contractor to revise an initial determination, revised
initial determination or redetermination; a Qualified Independent Contractor (QIC) to
revise a reconsideration; an Administrative Law Judge (ALJ) to revise a hearing decision,
and the Appeals Council (AC) to revise an ALJ decision or their own review decision.
Reopenings are generally not conducted until a party’s appeal rights have been exhausted
or the timeframe to file a request for an appeal has expired. There are two exceptions that

allow a reopening to be conducted when appeal rights have not been exhausted or the
timeframe to request an appeal has not expired. These exceptions are:
• 	Cases where Medical Review (MR) requested documentation, did not receive it,
and issued a denial based on no documentation (i.e., Group Code: CO -
Contractual Obligation; Claim Adjustment Reason Code (CARC) 50 - these are
non-covered services because this is not deemed a “medical necessity” by the
payer; and Remittance Advice Remark Code (RARC) M127 - Missing patient
medical record for this service). Subsequently, if the party requests an appeal and
submits the requested documentation with that appeal, it shall be treated as a
reopening; and
• 	Clerical errors (which includes minor errors and omissions) shall be treated as
reopenings.
If a contractor receives a valid and timely request for redetermination and begins
processing the request as a reopening (clerical error or otherwise) and later determines
that a reopening cannot be performed, or the determination cannot be changed, the
contractor shall not issue a refusal to reopen notice. Rather, the contractor shall process
the request as a valid/timely redetermination (as originally requested by the party) in
accordance with Pub. 100-04, chapter 29.
If a party has filed a valid request for an appeal, the adjudicator at the lower levels of the
appeals process loses jurisdiction to reopen the claim on the issues in question. For
example, a party simultaneously requests a QIC reconsideration and a reopening with the
contractor. The contractor can no longer reopen that redetermination decision now that
the party has filed a valid request for QIC reconsideration. This does not preclude
contractors from accepting and processing remands from the QIC.
As stated previously, it is within the contractor’s discretion to accept reopening requests,
but once accepted, they must be processed in accordance with the above instruction.
10.2 - Refusal to Reopen Is Not an Initial Determination
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
A finding that a prior determination or decision will not be reopened is not an “initial
determination or decision.” A contractor’s choice not to reopen is not appealable.
Accordingly, the contractor shall not include a statement concerning the right to an
appeal in the notice informing the party that their reopening request cannot be processed.
A party may however request an appeal on the original claim denial, but must do so
within the required timeframes. If a contractor receives a reopening request and does not
believe they can change the determination, they should not process the request.
10.3 - Reopenings of Denials Based on an Unanswered Additional
Documentation Request (ADR)
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)

If a claim is suspended for medical review, an ADR may be issued to obtain information
needed to make a determination. Providers, physicians, and suppliers are responsible for
providing the information needed to adjudicate their claims. If no response is received to
the ADR within the specified timeframes, the medical review department will likely deny
the service as not reasonable and necessary based on a lack of documentation.
If such a denial is appealed, the Medical Review department at the contractor shall
perform a reopening instead of an appeal if all of the following conditions are met:
1) 	A provider failed to timely submit documentation requested through an ADR;
2) 	The claim was denied because the requested documentation was not received
timely;
3) 	The requested documentation is received after the 45 day period with or without a
request for redetermination or reopening; AND,
4) 	The request is filed within 120 days of the date of receipt of the initial
determination.
If all 4 criteria are not present, the request is for a redetermination and it is submitted
within 120 days of the date of receipt of the initial determination, handle it as an appeal
and do not ship the case back to MR. In this instance, the request must meet the criteria
for a valid request for redetermination (see Pub. 100-04, Chapter 29, §310.1) in order for
the appeals unit to accept the request.
The CMS is handling these requests outside of the appeals process because CMS wants to
encourage providers, physicians and suppliers to submit documentation when requested
in order to prevent unnecessary appeals. Contractors should note that this requirement
does not extend the time frame for filing an appeal. Therefore, only those appeal requests
that are submitted within 120 days of the date of receipt of the initial determination and
meet all of the criteria above should be shipped back to MR for a reopening. When the
appeals unit ships cases back to the MR unit, MR must reopen those cases.
If the request is submitted after 120 days, contractors may grant a regular reopening at
their discretion or dismiss the request if no good cause explanation is provided for the
late filing.
If the ADR reopening results in an affirmation of the original denial or an adverse
decision, the provider will retain their right to a redetermination. The date of the MR
decision will be the date used to calculate the 120 days to request a redetermination.
10.4 - Reopenings Based on Clerical or Minor Errors and Omissions
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)

Section 937 of the Medicare Modernization Act (MMA) required CMS to establish a
process, separate from appeals, whereby providers, physicians and suppliers could correct
minor errors or omissions. We equate the MMA’s minor error or omission to fall under
our definition of clerical error, located in 42 CFR 405.980(a)(3). We believe that it is
neither cost efficient nor necessary for contractors to correct clerical errors through the
appeal process. Thus, 42 CFR 405.927 and 405.980(a)(3) require that clerical errors be
processed as reopenings rather than appeals. CMS defines clerical errors (including
minor errors or omissions) as human or mechanical errors on the part of the party or the
contractor, such as:
• 	Mathematical or computational mistakes;
• 	Transposed procedure or diagnostic codes;
• 	Inaccurate data entry;
• 	Misapplication of a fee schedule;
• 	Computer errors; or,
• 	Denial of claims as duplicates which the party believes were incorrectly identified
as a duplicate.
• 	Incorrect data items, such as provider number, use of a modifier or date of
service.
Note that clerical errors or minor errors are limited to errors in form and content, and that
omissions do not include failure to bill for certain items or services. A contractor shall
not grant a reopening to add items or services that were not previously billed, with the
exception of a few limited items that cannot be filed on a claim alone (e.g., G0369,
G0370, G0371 and G0374). Third party payer errors do not constitute clerical errors.
The law provides that reopenings may be done to correct minor errors or omissions, that
is, clerical errors. The contractor has discretion in determining what meets this definition
and therefore, what could be corrected through a reopening.
10.4.1 - Providers Submitting Adjustments
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
Part A providers that are able to submit an adjusted or corrected claim to correct an error
or omission may continue to do so and are not required to request a reopening.
Additionally, we encourage A/B MACs (A) and (HHH) who were handling the
corrections of such errors by advising providers to submit adjusted claims to instruct
providers that submitting adjusted claims continues to be the most efficient way to
correct simple errors.

10.5 - Telephone Reopenings - Required for A/B MACs (B) Only
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
NOTE: Since most A/B MACs (A) and (HHH) never processed telephone
redeterminations, CMS does not expect that A/B MACs (A) and (HHH) will process
many telephone reopenings, if any. However, they are not precluded from doing so,
should the telephone process prove effective. If A/B MACs (A) and (HHH) choose to
process telephone reopenings, they will be held to the same standards.
The majority of appeals processed as telephone redeterminations consisted of minor or
clerical errors that could be quickly corrected over the telephone. Section 937 of MMA
required CMS to establish a process to correct such errors outside of the appeals process.
Therefore, CMS has discontinued telephone redeterminations that were formerly
processed by A/B MACs (B) and DME MACs and has implemented the telephone
reopenings process. CMS believes that the vast majority of the work processed as
telephone redeterminations can instead be processed as telephone reopenings. A small
percentage of the work processed under telephone redeterminations will now fall under
written redeterminations and stay within the purview of the appeals units.
A/B MACs (B) and DME MACs shall allocate costs of reopenings that would have
formerly been processed as a telephone redetermination, but fall under the definition of a
clerical error under the claims reopenings Budget & Performance Requirements (BPR)
Code (11210). ADR reopenings that are shipped back to MR should be counted in the
appropriate MR BPR code.
The following sections describe the procedures for accepting and processing reopenings
over the telephone. CMS believes that most telephone reopenings will consist of clerical
errors or omissions that can be corrected quickly and easily over the telephone. That
does not preclude contractors from processing written requests for clerical error
reopenings. They may handle such requests either by phone or in writing.
Whether a request for reopening is made by telephone or is conducted and completed as a
telephone reopening depends on the issues at hand and the complexity of the matters
involved.
Receiving reopening requests and conducting reopenings on the telephone should
expedite and simplify the process. Requesting a reopening on the telephone provides
quick and easy access to parties who wish to correct clerical errors or omissions.
The contractor shall ensure that the Privacy Act of 1974, 5 USC, §552a, is applied to its
telephone reopening process. All staff that perform telephone reopenings shall be trained
on the Privacy Act requirements (see Pub. 100-01, chapter 6, Disclosure of Information).
10.5.1 - Informing the Provider Communities About the Telephone
Reopenings Process
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)

The contractor shall inform providers, physicians, and other suppliers of its telephone
reopenings process 30 days prior to initiation and annually thereafter or when making
significant changes to its process. It shall provide information about its process through
means such as Web sites, bulletins/newsletters, customer service/inquiry and provider
relations departments, conduct seminars, etc.
Information it publishes about its telephone reopenings process should include:
• 	How to access the process (telephone number, hours of operation, etc.);
• 	Any limitations (such as certain issues, number of claims/issues per call, etc.);
• 	Specific instructions that the party should state that he/she is requesting a
telephone reopening;
• 	Type of documentation that the party should have on hand when calling in to
request a reopening;
• 	The types of issues the contractor might be able to handle over the telephone and
the types of issues it will not handle over the telephone. Please see §10.5.2 below for
further discussion of issues that are appropriate for telephone reopenings.
10.5.2 - Issues for Telephone Reopenings
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
Telephone reopenings shall be limited to resolving minor issues and correcting errors as
defined in §10.4. As necessary, the contractor may ask the provider, physician, or
supplier to fax in documentation to support changes and error correction. If it appears
extensive documentation is required for review, please inform the requestor that they
should file a written request for reopening or file a request for an appeal, if applicable.
Telephone reopenings are generally inappropriate for the following issues:
• 	Limitation on liability;
• 	Medical necessity denials and reductions; or
• 	Analysis of documents such as operative reports and clinical summaries.
Contractors are not precluded from conducting a reopening on the issues listed above.
However, CMS believes that the issues above are usually too complex to be handled
appropriately over the phone in most instances.

In all cases, telephone reopenings are inappropriate for the following issues: Claims
requiring the input of medical staff or other entities outside of the reopenings department
and “big box” cases.
A. Issues That Can Not be Resolved During the Telephone Reopening
There may be instances where an issue cannot be resolved during the telephone
reopening. An issue may not be resolvable on the telephone because: (1) the issue
becomes too complex to be handled over the telephone and/or it is in the best interest of
the party to have a more in-depth review performed; or (2) there is a need for additional
medical documentation from the provider, physician, or other supplier.
If the issue cannot be resolved due to one of the preceding reasons, the contractor advises
the party that the reopening cannot be handled over the telephone. The contractor shall
instruct the party to either file a written request for reopening or file a written request for
appeal. Instruct the party that appeal requests must be filed within 120 days from the
date of the initial determination.
10.5.3 - Conducting the Telephone Reopening
(Rev. 4219, Issued: 01-25-19, Effective: 02-26-19, Implementation: 02-26-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Prior to conducting a telephone reopening, the caller must provide the following three
items:
• 	Verify the provider’s/physician’s/supplier’s name and identification number or
National Supplier Clearinghouse number;
• 	Beneficiary last name, first initial; and
• 	Medicare number.
Items must match exactly.
The contractor should also inform the caller that the call may be monitored for quality
assurance.
The following items shall be obtained/recorded/confirmed during telephone reopening:
• 	Date of call;

• 	Name of caller;
• 	Phone number of the party;
• 	Name of provider/physician/supplier of item or service;
• 	Dates of service;
• 	Which items(s) or service(s) are at issue;
• 	Reason for the request;
• 	Any new information that is received during the telephone call;
• 	Rationale for not processing the request, if applicable;
• 	Any appeal rights, if applicable;
• 	Name of the reviewer;
• 	Confirmation number, if applicable; and
• 	Inform the caller that the call may be monitored.
10.5.4 - Documenting the Telephone Reopening
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
The information received during the telephone reopening (especially the date of the call)
must be either: (1) documented on a reopening documentation form; or (2) logged into
the contractor’s computer system.
All documentation must be assigned a control number. Any additional documentation
received must be recorded into the contractor system or attached to the form. The
telephone reopening control number is recorded on all documents received that are
associated with the telephone reopening, if applicable. The documents are included in
the file.
Although documentation should rarely be necessary during a telephone reopening, the
documentation must be made a part of the file and be available if an appeal is requested
based on any revised determination issued as a result of the reopening. All
documentation should be maintained in a manner that allows for future audits.
10.5.5 - Monitoring the Telephone Reopening
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)

CMS may review this function at any time so the contractor may want to develop and
maintain records on a monitoring/quality assurance process.
10.6 - Timeframes to Reopen Claim Determinations
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
Our regulations establish timeframes that restrict the ability of the contractor to reopen
claim determinations. See 42 CFR 405.980(b) and (c) for the timeframes for reopenings.
The specific timeframes for contractor-initiated and party-requested reopenings are
detailed below.
10.6.1 - Timeframes for Contractor Initiated Reopenings
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
A contractor may reopen and revise its initial determination or redetermination on its own
motion:
• 	Within 1 year from the date of the initial determination or redetermination for any
reason; or
• 	Within 4 years from the date of the initial determination or redetermination for
good cause as defined in §10.11; or
• 	At any time if:
o 	There exists reliable evidence that the initial determination was procured
by fraud or similar fault as defined in 42 CFR 405.902; or
o 	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 as defined in §10.4; or,
• 	At any time to effectuate a coverage decision issued under 42 CFR
426.460(b)(1)(i), 426.488(b) and (c) or 426.560 (b)(1)(i) appeals process.
10.6.2 - Timeframes for Party Requested Reopenings
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
A party may request a contractor reopen and revise its initial determination or
redetermination under the following conditions:
• 	Within 1 year from the date of the initial determination or redetermination for any
reason; or

• 	Within 4 years from the date of the initial determination or redetermination for
good cause as defined in §10.11; or,
• 	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
as defined in §10.4.
While a contractor can reopen at any time under the limited criterion set forth above to
correct an unfavorable determination, CMS does not expect that a contractor would
regularly grant these requests, especially for older claims where the claims history is not
readily available. Both the contractor and the provider/physician/supplier have a
reasonable expectation to administrative finality in the processing of their claims.
Additionally, administrative efficiency and the ability of a Medicare contractor to
continue vital functions (i.e., process Medicare claims and process appeal requests)
require that contractors grant such requests rarely.
10.6.3 - Timeframes for Adjudicator to Reopen
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)A
QIC, ALJ or the AC may reopen and revise its reconsideration, hearing decision or
review, respectively, under the following conditions:
• 	Within 180 days from the date of its decision for good cause in accordance with
42 CFR 405.986; or,
• 	At any time if the reconsideration, hearing decision or review was procured by
fraud or similar fault.
10.6.4 - Timeframes When a Party Requests an Adjudicator Reopen
Their Decisions
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
A party may request a QIC, ALJ or the AC reopen and revise its reconsideration, hearing
decision or review within 180 days from the date of the reconsideration, hearing decision
or review, as applicable, for good cause in accordance with 42 CFR 405.986.
10.7 - Timeframes to Complete a Reopening Requested by a Party
(Rev. 2241; Issued: 06-17-11, Effective: 10-01-11, Implementation: 10-03-11)
There are no timeframes established in statute or regulation governing the timeframes for
a contractor to complete a reopening action. However, a party to an initial determination
has a reasonable expectation to the administrative finality of a determination issued by
Medicare. Therefore, this section sets out timeframes to complete the reopening action
once the reopening has been initiated. These timeframes apply only to those reopening

requests that are requested by the party to the initial determination. These timeframes do
not apply to contractor initiated reopenings.
For those reopenings requested by a party that the contractor agrees to reopen, the
contractor shall complete the reopening action 60 days from the date of receipt of the
party’s reopening request in the corporate mailroom, receipt in a secure Internet
portal/application, or receipt of the telephone request. This does not apply to “big box
cases” defined as aggregated requests filed by a provider, physician, or other supplier that
involve 40 or more beneficiaries/claims and $40,000 or more in controversy.
10.8 - Notice of a Revised Determination or Decision
(Rev. 2241; Issued: 06-17-11, Effective: 10-01-11, Implementation: 10-03-11)
If the reopening action results in a revised determination or decision that results in
payment to a provider, physician, or supplier, a revised electronic or paper remittance
advice notice must be issued by the Medicare contractor and will satisfy the notice
requirements. If applicable, a revised Medicare Summary Notice will suffice for notice
to the beneficiary in the above instances. If the reopening action results in an adverse
revised determination or decision the contractor shall mail, or if approved by CMS,
transmit via a secure Internet portal/application a letter that states the rationale and basis
for the reopening and revision and any right to appeal. The timeframe to request the
appeal would be based on the date of the contractor’s revised determination. If the
contractor cannot change the original determination or chooses to not accept the request,
the contractor should inform the requestor that the contractor cannot process their
reopening request. If the request is over the telephone, the contractor can verbally inform
the caller that they cannot process their request. If it is a written reopening request
submitted via hard copy or a secure Internet portal/application, the contractor shall send a
brief letter via mail or, if approved by CMS, a secure Internet portal/application,
informing the requestor that they cannot process the request. The contractor should state
that their decision to not reopen a claim determination is not an initial determination and
is therefore not appealable.
10.9 - Revised Determination or Decision
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
A revised determination or decision is one in which:
• 	The end result is changed (e.g., a service previously found to be covered is now
found not to be covered or the allowable charge for the service is determined to be
incorrect); or
• 	The end result is not changed, but a party might be disadvantaged by the revision
(e.g., a request for payment on a claim previously disallowed because the services were
not medically necessary and therefore subject to the limitation on liability provisions, is
now to be disallowed on a basis that precludes consideration of limitation on liability).

10.10 - Effect of a Revised Determination or Decision
(Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06)
The revision of an initial determination is binding on all parties unless a party files a
written request for a redetermination of the revised determination that is accepted and
processed. The request for a redetermination must be filed within 120 days from the date
of the revised initial determination. The revision of a redetermination is binding on all
parties unless a party files a written request for a QIC reconsideration that is accepted and
processed.
10.11 - Good Cause for Reopening
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
On its own initiative or at the request of party (see IOM Pub. 100-04, chapter 29, §110
for the definition of a party), a contractor may reopen an initial determination or
redetermination within 4 years from the date of the initial determination or
redetermination when good cause exists. However, good cause is not required for
reopening of claims for up to 1 year from the date of the initial determination or
redetermination. Under 42 CFR 405.986, good cause exists when:
• 	There is new and material evidence that was not available or known at the time of
the determination or decision and may result in a different conclusion; or
• 	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.
A contractor’s decision to reopen based on the existence of good cause, or refusal to
reopen after determining good cause does not exist, is not subject to appeal. See 42 CFR
405.926(l), and 405.980(a)(5).
NOTE: Third party payer error in making a primary payment determination does not
constitute good cause for the purposes of reopening an initial determination or
redetermination when Medicare processed the claim in accordance with the information
in its system of records or on the claim form. Contractors may only reopen for third party
payer error under the “within one year for any reason” standard. This is true for both
contractor initiated reopenings as well as reopenings requested by a party. All providers
and suppliers have a legal obligation to determine the correct primary payer when billing
Medicare. Failure to do so, regardless of third party payer error, does not constitute
“good cause” that will permit reopening beyond one year. Information regarding such
error does not constitute “new and material evidence.”
10.11.1 - What Constitutes New and Material Evidence
(Rev. 1671, Issued: 01-16-09; Effective/Implementation Date: 02-16-09)

New and material evidence is one of the means for establishing good cause to reopen an
initial determination or redetermination. New and material evidence is evidence that:
1. 	Was not readily available or known to the person or entity requesting/initiating
the reopening at the time of the initial determination or redetermination; and
2. 	May result in a conclusion different from that reached in the initial determination
or redetermination.
For example, data analysis that identifies a high error rate or pattern of potential
overutilization on the part of a provider or supplier is one example of evidence that is not
readily available or known to a contractor at the time it made its initial determination, and
may cause the contractor to believe its initial determinations for the claims of the
provider or supplier were incorrect.
Evidence may include any record used in the provision of medical care that supports
whether or not the service was covered, medically necessary, and provided as billed.
This includes medical records, progress notes, orders, procedure reports, invoices, proofs
of delivery, or other documentation as required by CMS policy. However, as explained
further below, any such evidence submitted by a party must satisfy the good cause
standard set forth in §405.986 (i.e., that it is new and material evidence (as described
above), or demonstrates that the evidence considered in making the initial determination
or redetermination clearly shows on its face that an obvious error was made at the time of
the determination or decision).
10.11.2 - Policies Related to Good Cause Reopenings for New and
Material Evidence
(Rev. 1671, Issued: 01-16-09; Effective/Implementation Date: 02-16-09)
In determining whether good cause exists for reopening an initial determination or
redetermination, the contractor considers whether evidence is new and material from the
perspective of the person or entity requesting or initiating the reopening.
When a party requests a reopening of an initial determination or redetermination for good
cause based on the submission of new and material evidence, the following policies
apply:
• 	The mere submission of additional evidence is not necessarily sufficient to
establish good cause to reopen an initial determination or decision. The information must
be “new,” (i.e., not readily available or known to exist at the time of the initial
determination) as well as material (i.e., may result in a different conclusion). A party
should explain how the information constitutes new and material evidence that
establishes good cause. If the contractor is unable to determine whether the information
submitted with a reopening request constitutes new and material evidence, the contractor
may decide not to grant the reopening.

• 	When a request for reopening is submitted with new and material evidence, but
additional information or evidence is needed before a proper revised determination or
decision can be made, the contractor may contact the party seeking the reopening, and
request that they obtain and submit the additional information. If the person or entity
requesting the reopening cannot obtain the additional information, the Medicare
contractor assists to the extent that it is reasonably able to do so.
When a Medicare contractor initiates a reopening of an initial determination or
redetermination for good cause based on the existence of new and material evidence, the
following policies apply:
• 	The contractor is responsible for clearly documenting in the case file the new and
material evidence that represents good cause for reopening.
• 	In order to promote administrative efficiency, Medicare does not generally require
that a party submit supporting medical documentation with the initial claim. Therefore, if
a medical record or other supporting documentation was not utilized when a contractor
made an initial determination, because it was not requested or was not provided, then the
content of any medical records or supporting documentation which are subsequently
requested by the contractor during the course of its review would constitute new
evidence.
10.11.3 - What Constitutes Error on the Face of the Evidence
(Rev. 1671, Issued: 01-16-09; Effective/Implementation Date: 02-16-09)
Error on the face of the evidence exists if it is clear that the determination or decision was
incorrect based on all evidence in file on which the determination or decision was based,
or any evidence of record anywhere in the contractor’s Medicare file or in CMS files at
the time such determination or decision was made.
10.12 - Change in Substantive Law or Interpretative Policy
(Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16)
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 decision
under this section. This provision does not preclude contractors from conducting
reopenings to effectuate coverage decisions issued under 42 CFR 42 CFR
§426.460(b)(1)(i), 426.488 (b) and (c), or 426.560(b)(1)(i) appeals process..
10.13 – System and Processing Requirements for Use of Secure Internet
Portal/Application to Support Reopening Activities
(Rev. 2241; Issued: 06-17-11, Effective: 10-01-11, Implementation: 10-03-11)

Contractors who develop and utilize a secure Internet portal/application for reopening
purposes shall ensure, at a minimum:
• 	CMS approves (i.e., Contract Manager or Project Officer, if applicable, and
Appeals Business Function Lead) the proposed portal/application and usage prior
to development and implementation.
• 	The portal/application fully complies and has been tested to ensure compliance
with all CMS system security requirements regarding protected health
information prior to implementation/usage.
• 	The secure Internet portal/application includes a formal registration process that
validates the signature. This process shall include, at a minimum, use of restricted
user identifiers (IDs) and passwords. Contractors shall include an indication
and/or description of the validation methodology in the appeals case file should an
appeal on the item/service reopened be requested.
• 	Templates for submission of electronic reopening request shall include, at a
minimum, a method for authenticating that the party has completed the
portal/application registration process and has been properly identified by the
system as an appropriate user.
• 	Contractors utilizing an approved portal/application shall provide education to
parties to the reopening regarding system capabilities/limitations prior to
implementation and utilization of the secure portal/application.
• 	Contractors shall also educate parties to the reopening that
participation/enrollment in the secure portal/application is at the discretion of the
party and the party bears the responsibility for the authenticity of the information
being attested to.
• 	Appropriate procedures are in place to provide parties with confirmation of
receipt of the reopening request via secure Internet/portal and verbiage instructing
the parties not to submit additional reopening requests for the same item or
service via different venue (hard copy mail or telephone).
• 	Contractors utilizing a secure portal/application shall ensure that there is a process
in place by which a party can submit additional documentation/materials
concurrent with the reopening request. The portal/application shall have the
capability to accept additional documentation and/or other materials to support
reopening requests.
• 	Refusal to reopen and adverse revised determination notices transmitted via a
secure Internet portal/application shall comply with the timeliness and content
requirements as outlined in the Pub. 100-04, chapter 34. In addition, contractors
shall provide hard copy decision notices to parties to the reopening, as required,

who do not have access to the secure Internet portal/application. The notices must
be mailed and/or otherwise transmitted concurrently (i.e., mailed on the same day
the notice is transmitted via the secure portal/application).
• 	Contractors utilizing a secure Internet portal/application shall include the adverse
revised determination/decision notice and any other related materials in the
appeals case file if a valid appeal on the item/service is later requested.
• 	Contractors shall also ensure that parties may save and print the revised adverse
determination/decision notice or refusal to reopen notice and that the secure
portal/application includes a mechanism by which the date/time of the notification
is tracked/marked both in the system and on any printed decision notices so as to
adequately inform the party of timeframes for ensuring timely submission of
future appeal requests.

Transmittals Issued for this Chapter
Rev # 	Issue Date Subject 	Impl Date CR#
R4219CP 01/25/2019 Update to Pub. 100-04 Chapter 34 to Provide
Language-Only Changes for the New
Medicare Card Project
02/26/2019 11115
R3568CP 07/29/2016 Reopenings Update - Changes to Chapter 34 	09/30/2016 9639
R2241CP 06/17/2011 Guidelines to Allow Contractors to Develop
and Utilize Procedures for Accepting and
Processing Reopenings Via a Secure Internet
Portal/Application
10/03/2011 7420
R1671CP 01/16/2009 Clarification of Requirements for New and
Material Evidence as Good Cause for
Reopening
02/16/2009 6157
R1069CP 09/29/2006 Initial Release of Chapter-Reopenings and
Revisions of Claim Determinations and
Decisions
11/29/2006 4147
Back to top of chapter