42 CFR 405.986 - Good cause for reopening.

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§ 405.986 Good cause for reopening.

(a)Establishing good cause. 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) 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

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.

[ 70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37703, June 30, 2005]

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

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United States Code
Statutes at Large

Title 42 published on 16-Nov-2018 03:48

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 405 after this date.

  • 2018-11-23; vol. 83 # 226 - Friday, November 23, 2018
    1. 83 FR 59836 -  
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Final rules and interim final rule.
      42 CFR Part 405