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. § 405.986

Good cause for reopening

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(a) Establishing good cause for reopening. 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 Medicare 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; 86 FR 65660, Nov. 19, 2021]
Notes of Decisions
Cited in 4 cases (2 in the last 5 years), 2012–2024 · leading case: D&G Holdings v. Becerra, 22 F.4th 470 (5th Cir. 2022).
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D&G Holdings v. Becerra, 22 F.4th 470 (5th Cir. 2022). “” 42 CFR § 405.986 (a). The Secretary’s barely-argued motion does not address or even attempt to establish Novitas’s good cause.”
St. Francis Hosp. v. Sebelius, 874 F. Supp. 2d 127 (E.D.N.Y 2012). “¶ 59, 68 (citing 42 C.F.R. 405.986).) No new evidence was available at the time of reopening that was not previously available at the time of the initial determination.”
St. Francis Hosp. v. Sebelius, 34 F. Supp. 3d 234 (E.D.N.Y 2014). “42 C.F.R. § 405.986 (a). . Notably,-an initial determination can be reopened within the first year for any reason.”
Consultants in Pain Med., PLLC & David Blanton v. Ellen Boyle Duncan, PLLC & Ellen Boyle Duncan, M.D. (Tex. App. 2024). “Qlarant’s letter states: Qlarant is authorized to reopen claims due to the rules cited in 42 CFR § 405.986 . Good cause for reopening may be established when new and material evidence was not available or known at the time of the original determination or decision and may result…”
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