[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR478.48]



[Page 481-482]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 478_RECONSIDERATIONS AND APPEALS--Table of Contents

 

     Subpart B_Utilization and Quality Control Quality Improvement 

             Organization (QIO) Reconsiderations and Appeals

 

Sec.  478.48  Reopening and revision of a reconsidered determination or 



a hearing 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 Sec.  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 QIO or QIO subcontractor may reopen 

and revise its reconsidered determination, or its review of a DRG change 

as described in Sec.  473.15, 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 and Departmental Appeals Board Reopening--Applicable 

procedures.



[[Page 482]]



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 Sec.  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.



[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]