RAC Time Frames
John Paul Coder-Biller
Description
Collection
Title:
RAC Time Frames
Creator:
John Paul Coder-Biller
Date:
11/6/2013
Text:
Sorry this is so long, but it is good information for all of you like
myself who are interested in time frames.
I had posted earlier with reference to time frames for RAC audits. With
reference to Health DataInsights, Region D, RAC, they are quoting 42 CFR
405.980(b), as establishing good cause for reopening.
42 CFR 405.980 - Reopenings of initial determinations, redeterminations,
and reconsiderations, hearings and reviews.
(b) Time frames and requirements for reopening initial determinations
and redeterminations initiated by a contractor. A contractor may reopen
an initial determination or redetermination on its own motion—
(1) Within 1 year from the date of the initial determination or
redetermination for any reason.
(2) Within 4 years from the date of the initial determination or
redetermination for good cause as defined in § 405.986.
(3) At any time if there exists reliable evidence as defined in §
405.902 that the initial determination was procured by fraud or similar
fault as defined in § 405.902.
(4) At anytime if the initial determination is unfavorable, in whole
or in part, to the party thereto, but only for the purpose of correcting
a clerical error on which that determination was based.
(5) At any time to effectuate a decision issued under the coverage
appeals process.
(c) Time frame and requirements for reopening initial determinations
and redeterminations requested by a party. (1) A party may request
that a contractor reopen its initial determination or redetermination
within 1 year from the date of the initial determination or
redetermination for any reason.
(2) A party may request that a contractor reopen its initial
determination or redetermination within 4 years from the date of the
initial determination or redetermination for good cause in accordance
with § 405.986.
(3) A party may request that a contractor reopen its initial
determination at any time if the initial determination is unfavorable,
in whole or in part, to the party thereto, but only for the purpose of
correcting a clerical error on which that determination was based. Third
party payer error does not constitute clerical error. See § 405.986(c).
(d) Time frame and requirements for reopening reconsiderations, hearing
decisions and reviews initiated by a QIC, ALJ, or the MAC. (1) A QIC
may reopen its reconsideration on its own motion within 180 calendar
days from the date of the reconsideration for good cause in accordance
with § 405.986. If the QIC's reconsideration was procured by fraud or
similar fault, then the QIC may reopen at any time.
(2) An ALJ or the MAC may reopen a hearing decision on its own motion
within 180 calendar days from the date of the decision for good cause in
accordance with § 405.986. If the hearing decision was procured by
fraud or similar fault, then the ALJ or the MAC may reopen at any time.
(3) The MAC may reopen its review decision on its own motion within
180 calendar days from the date of the review decision for good cause in
accordance with § 405.986. If the MAC's decision was procured by fraud
or similar fault, then the MAC may reopen at any time.
(e) Time frames and requirements for reopening reconsiderations,
hearing decisions, and reviews requested by a party. (1) A party to a
reconsideration may request that a QIC reopen its reconsideration within
180 calendar days from the date of the reconsideration for good cause in
accordance with § 405.986.
(2) A party to a hearing may request that an ALJ or the MAC reopen a
hearing decision within 180 calendar days from the date of the hearing
decision for good cause in accordance with § 405.986.
(3) A party to a review may request that the MAC reopen its decision
within 180 calendar days from the date of the review decision for good
cause in accordance with § 405.986.
John
Biller/Coder
myself who are interested in time frames.
I had posted earlier with reference to time frames for RAC audits. With
reference to Health DataInsights, Region D, RAC, they are quoting 42 CFR
405.980(b), as establishing good cause for reopening.
42 CFR 405.980 - Reopenings of initial determinations, redeterminations,
and reconsiderations, hearings and reviews.
(b) Time frames and requirements for reopening initial determinations
and redeterminations initiated by a contractor. A contractor may reopen
an initial determination or redetermination on its own motion—
(1) Within 1 year from the date of the initial determination or
redetermination for any reason.
(2) Within 4 years from the date of the initial determination or
redetermination for good cause as defined in § 405.986.
(3) At any time if there exists reliable evidence as defined in §
405.902 that the initial determination was procured by fraud or similar
fault as defined in § 405.902.
(4) At anytime if the initial determination is unfavorable, in whole
or in part, to the party thereto, but only for the purpose of correcting
a clerical error on which that determination was based.
(5) At any time to effectuate a decision issued under the coverage
appeals process.
(c) Time frame and requirements for reopening initial determinations
and redeterminations requested by a party. (1) A party may request
that a contractor reopen its initial determination or redetermination
within 1 year from the date of the initial determination or
redetermination for any reason.
(2) A party may request that a contractor reopen its initial
determination or redetermination within 4 years from the date of the
initial determination or redetermination for good cause in accordance
with § 405.986.
(3) A party may request that a contractor reopen its initial
determination at any time if the initial determination is unfavorable,
in whole or in part, to the party thereto, but only for the purpose of
correcting a clerical error on which that determination was based. Third
party payer error does not constitute clerical error. See § 405.986(c).
(d) Time frame and requirements for reopening reconsiderations, hearing
decisions and reviews initiated by a QIC, ALJ, or the MAC. (1) A QIC
may reopen its reconsideration on its own motion within 180 calendar
days from the date of the reconsideration for good cause in accordance
with § 405.986. If the QIC's reconsideration was procured by fraud or
similar fault, then the QIC may reopen at any time.
(2) An ALJ or the MAC may reopen a hearing decision on its own motion
within 180 calendar days from the date of the decision for good cause in
accordance with § 405.986. If the hearing decision was procured by
fraud or similar fault, then the ALJ or the MAC may reopen at any time.
(3) The MAC may reopen its review decision on its own motion within
180 calendar days from the date of the review decision for good cause in
accordance with § 405.986. If the MAC's decision was procured by fraud
or similar fault, then the MAC may reopen at any time.
(e) Time frames and requirements for reopening reconsiderations,
hearing decisions, and reviews requested by a party. (1) A party to a
reconsideration may request that a QIC reopen its reconsideration within
180 calendar days from the date of the reconsideration for good cause in
accordance with § 405.986.
(2) A party to a hearing may request that an ALJ or the MAC reopen a
hearing decision within 180 calendar days from the date of the hearing
decision for good cause in accordance with § 405.986.
(3) A party to a review may request that the MAC reopen its decision
within 180 calendar days from the date of the review decision for good
cause in accordance with § 405.986.
John
Biller/Coder
Citation
John Paul Coder-Biller, “RAC Time Frames,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/235808.
