42 CFR § 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG validations.
(1) Within one year of the date of the claim containing the service in question, may review and deny payment; and
(b) Extended timeframes.
(1) An initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the claim containing the service in question, if CMS approves.
(i) Additional information is received on the patient's condition;
(ii) Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;
(iii) There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or
(c) Fraud and abuse.
(2) An initial denial determination or change as a result of a DRG validation may be reopened and revised anytime there is a finding that it was obtained through fraud or a similar abusive practice that does not support a finding of fraud.