Reopenings
Timeliness Requirements
The time period during which a determination or decision may be reopened under the above 3-year rules commences on the date of the Notice of Amount of Program Reimbursement containing the intermediary's determination. The 3-year period ends on the third anniversary of that date. Where the period for reopening expires on a Saturday, Sunday, legal holiday or any other day, all or part of which is a non-workday by Federal statute or Executive order, the period is extended to the next full workday.
To meet the three-year requirement, the provider's request, including all of the supporting documentation necessary to determine if a reopening is warranted, must be submitted (postmarked) within three years of the original NPR. Providers are encouraged to file any request for reopening well in advance of the final date for submission to allow time to cure any deficiency in the request. Reopening requests denied due to inadequate or incomplete definition or support cannot be reopened after expiration of the three-year limit on reopenings. Providers are reminded that submitting a reopening request will not protect their appeal rights, which can only be preserved by timely filing an appeal with PRRB within 180 days of the NPR.
Contact Information
To ensure a timely response to your requests, the following addresses should be used when sending correspondence requesting a cost report reopening:
| Regular Postal Service: | Delivery/Overnight Service: |
| WPS Medicare South 7
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WPS Medicare South 7
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| P.O. Box 1604
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3333 Farnam Street
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| Omaha, NE 68101
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Omaha, NE 68131
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Should you have any questions regarding the receipt or status of the cost report reopening, or general cost report reopening questions, please contact the Audit Supervisor assigned to your provider at 1-866-734-9444 or refer to our Home Office Contacts page.
General Information
For the purpose of the reopening and correction provisions, an intermediary's initial determination (Notice of Amount of Program Reimbursement) becomes final and binding upon the expiration of 180 calendar days after the date of mailing of the notice, unless before that time the provider requests a hearing before the Provider Reimbursement Review Board (PRRB). If a hearing is denied, the determination becomes final at the end of the 180-day period. If the hearing is granted, the provisions with respect to finality of a hearing decision become applicable.
An intermediary's determination, otherwise final, may nevertheless be reopened and corrected when the specific requirements for reopening and correction are met. The term "reopening" means an affirmative action taken by an intermediary to reexamine or question the correctness of a determination or decision otherwise final. Such action may be taken on the initiative of the intermediary within the applicable time period; or in response to a written request of the provider filed with the intermediary within the applicable time period. Note that jurisdiction for a reopening rests exclusively with the administrative body that rendered the last determination or decision for that cost reporting period. Normally that body will be the intermediary, however, in certain situations a reopening may be done at the direction of the PRRB or a Federal Court.
An intermediary's initial determination on the amount of program payment contained in a Notice of Amount of Program Reimbursement, which is otherwise final, may be reopened by the intermediary within 3 years of the date of such notice. A determination or decision will be reopened and corrected at any time if it is found that such determination or decision was procured by fraud or similar fault by any party to the determination or decision. (Refer to the Code of Federal Regulation (CFR), Title 42, Section 405.1885 - 405.1889).
The decision by the intermediary as to whether or not they will reopen a determination, otherwise final, must be based on:
- New and material evidence, or
- A clear and obvious error, or
- The determination is found to be inconsistent with the law, regulations and rulings, or general instructions.
Note that the reopening regulations do not require a reopening based on these criteria, but merely permit it. As such, we will be taking a conservative view as to what will be considered. For example, evidence that was in, or should have been in the provider's possession during our initial audit, but for whatever reason was not provided to us, will not be considered "new". Also keep in mind that once a cost report is filed, the provider is bound by its elections. A provider may not file an amended cost report to avail itself of an option it did not originally elect. Therefore as part of a reopening request, we will not consider any changes to elections made on the part of the provider in the as-filed cost report.
Where a correction is made by an intermediary in a determination on the amount of program payment which it has reopened, such correction shall be considered a separate and distinct determination to which the hearing provisions apply; i.e., if as a result of the correction, there is a sufficient amount of Medicare program payment in dispute, the provider has a right to a hearing on the correction if it files a request for one within 180-calendar days of the date of the Notice of Correction of Program Reimbursement. The correction of a determination or decision will be final and binding on the provider unless the provider files a written request for a hearing on the corrected determination. This right to a hearing only extends to those items or issues revised or adjusted as part of the correction.
Page Last Updated: Wednesday, 31-Dec-2008 10:49:05 CST
