Your Good Cause May Not Be Good Enough

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CMS has clarified the "new and material information" standard for reopening claims for good cause, when more than a year has passed since the claim was initially paid or denied. On January 16, 2009, CMS released Transmittal 1671, which clarifies what constitutes good cause. Good cause is said to exist when the information reviewed during the initial determination clearly contained an error on its face or when there is "new and material" information that was "not available or known" during the initial claim determination and when that information could result in a different determination or decision. As such, providers and suppliers seeking to reopen a claim must submit additional documentation along with an explanation of how it establishes good cause. Merely submitting evidence that was not previously submitted will no longer be sufficient to meet the good cause standard; the evidence must not have been known or readily available at the time of the initial determination.

The good cause standard still gives contractors great leeway to reopen claims. Ober|Kaler's Carel Hedlund and Lisa Stevenson discuss.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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