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Code of Federal Regulations (Last Updated: July 5, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter D - State Children'S Health Insurance Programs (Schips) |
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Part 473 - RECONSIDERATIONS AND APPEALS |
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Subpart B - Utilization and Quality Control Peer Review Organization (PRO) Reconsiderations and Appeals |
§ 473.48 - Reopening and revision of a reconsidered determination or a hearing decision.
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(a)
PRO reopenings— (1)General rule . A PRO or PRO subcontractor that made a reconsidered determination, or conducted a review of a DRG change as described in § 473.15, 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 PRO or PRO subcontractor may reopen and revise its reconsidered determination, or its review of a DRG change as described in § 473.15, that is otherwise binding, after one year but within four years of the date of the determination or review if—(i) The PRO receives new material evidence;
(ii) The PRO 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 and Departmental Appeals Board Reopening—Applicable procedures . The ALJ or the Departmental Appeals Board, whichever made the decision, may reopen and revise the decision in accordance with the procedures set forth in § 405.750(b) of this chapter, which concerns reopenings and revisions under subpart G 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 the Departmental Appeals Board 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.