Timeframes for Party Requested Reopenings

10.6.2 - Timeframes for Party Requested Reopenings (Rev. 3568, Issued: 07-29-16, Effective: 09-30-16, Implementation: 09-30-16) A party may request a contractor reopen and revise its initial determination or redetermination under the following conditions: • Within 1 year from the date of the initial determination or redetermination for any reason; or • Within 4 years from the date of the initial determination or redetermination for good cause as defined in §10.11; or, • 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 as defined in §10.4. While a contractor can reopen at any time under the limited criterion set forth above to correct an unfavorable determination, CMS does not expect that a contractor would regularly grant these requests, especially for older claims where the claims history is not readily available. Both the contractor and the provider/physician/supplier have a reasonable expectation to administrative finality in the processing of their claims. Additionally, administrative efficiency and the ability of a Medicare contractor to continue vital functions (i.e., process Medicare claims and process appeal requests) require that contractors grant such requests rarely.