C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.984

Effect of a revised determination or decision

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(a) Initial determinations. The revision of an initial determination is binding upon all parties unless a party files a written request for a redetermination that is accepted and processed in accordance with § 405.940 through § 405.958.

(b) Redeterminations. The revision of a redetermination is binding upon all parties unless a party files a written request for a QIC reconsideration that is accepted and processed in accordance with § 405.960 through § 405.978.

(c) Reconsiderations. The revision of a reconsideration is binding upon all parties unless a party files a written request for an ALJ hearing that is accepted and processed in accordance with § 405.1000 through § 405.1063.

(d) ALJ or attorney adjudicator decisions. The revision of an ALJ or attorney adjudicator decision is binding upon all parties unless a party files a written request for a Council review that is accepted and processed in accordance with § 405.1100 through § 405.1130.

(e) Council review. The revision of a Council review is binding upon all parties unless a party files a civil action in which a Federal district court accepts jurisdiction and issues a decision.

(f) Appeal of only the portion of the determination or decision revised by the reopening. Only the portion of the initial determination, redetermination, reconsideration, or hearing decision revised by the reopening may be subsequently appealed.

(g) Effect of a revised determination or decision. A revised determination or decision is binding unless it is appealed or otherwise reopened.

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5108, Jan. 17, 2017]
Notes of Decisions
Cited in 5 cases (2 in the last 5 years), 2010–2026 · leading case: Almy v. Sebelius
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Almy v. Sebelius (2012) ca4 “The Secretary’s promulgated regulations make clear that a decision by a contractor or ALJ is only binding on the parties to that particular case, and that a decision is not binding once “a party files a written request for a MAC review that is accepted and processed.”
Palomar Medical Center v. Kathleen Sebelius (2012) ca9 · cites it 2× “” 42 C.F.R. § 405.984 (a), (f). In the preamble to the interim final rule on reopenings, CMS responded to comments about enforcement of the good cause standard.”
MORTON PLANT HOSPITAL ASSOCIATION, INC. v. Sebelius (2010) flmd “” 42 C.F.R. § 405.984 . However, the Recovery Contractor’s decision of whether or not to reopen the claim is not appealable.”
First United Methodist Church v. Becerra (2022) ned “980 (a); see also 42 C.F.R. § 405.984 (establishing that a reopening can revise initial determinations, redeterminations, reconsiderations, ALJ or attorney adjudicator decisions, and Medicare Appeals Council decisions).”
In re: IHN Podiatry Services, PLLC (2026) flmb “67 When determined that a Medicare supplier received an overpayment, the contractor starts the overpayment recovery process by sending a demand letter requiring repayment.”
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