42 CFR § 478.48 - Reopening and revision of a reconsidered determination or a decision.

---
identifier: "/us/cfr/t42/s478.48"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 478.48 - Reopening and revision of a reconsidered determination or a decision."
title_number: 42
title_name: "Public Health"
section_number: "478.48"
section_name: "Reopening and revision of a reconsidered determination or a decision."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "F"
subchapter_name: "QUALITY IMPROVEMENT ORGANIZATIONS"
part_number: "478"
part_name: "RECONSIDERATIONS AND APPEALS"
positive_law: false
currency: "2026-04-05"
last_updated: "2026-04-05"
format_version: "1.1.0"
generator: "[email protected]"
authority: "Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh)."
cfr_part: "478"
---


# 478.48 Reopening and revision of a reconsidered determination or a decision.

(a) *QIO reopenings*—(1) *General rule.* A QIO or QIO subcontractor that made a reconsidered determination, or conducted a review of a DRG change as described in § 478.15, that is otherwise binding, may reopen and revise the reconsidered determination or review, either on its own motion or at the request of a party, within one year from the date of the reconsidered determination or review.

(2) *Extension of time limit.* A QIO or QIO subcontractor may reopen and revise its reconsidered determination, or its review of a DRG change as described in § 478.15, that is otherwise binding, after one year but within four years of the date of the determination or review if—

(i) The QIO receives new material evidence;

(ii) The QIO erred in interpretation or application of Medicare coverage policy;

(iii) There is an error apparent on the face of the evidence upon which the reconsidered determination was based; or

(iv) There is a clerical error in the statement of the reconsidered determination.

(b) *ALJ or attorney adjudicator and Council Reopening—Applicable procedures.* The ALJ or attorney adjudicator, or the Council, whichever made the decision, may reopen and revise the decision in accordance with the procedures set forth in § 405.980 of this chapter, which concerns reopenings and revised decisions under subpart I of part 405 of this chapter.

(c) *Fraud or similar abusive practice.* A reconsidered determination, a review of a DRG change, or a decision of an ALJ or attorney adjudicator, or the Council may be reopened and revised at any time, if the reconsidered determination, review, or decision was obtained through fraud or a similar abusive practice that does not support a formal finding of fraud.

[50 FR 15372, Apr. 17, 1985, as amended at 61 FR 32349, June 24, 1996; 62 FR 25855, May 12, 1997. Redesignated at 64 FR 66279, Nov. 24, 1999; 77 FR 68563, Nov. 15, 2012; 82 FR 5140, Jan. 17, 2017]