Reopening Thresholds and Requirements
In accordance with and PRM 15-1, Section 2931.2, whether or not CGS will reopen a determination, otherwise considered final, will depend upon whether new and material evidence has been submitted, or a clear and obvious error was made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions. In the absence of explicit direction from the Centers for Medicare and Medicaid Services (CMS), it is the MAC’s decision whether or not to reopen a Medicare cost report.
The request must be received no later than 3 years after the date of the determination (Notice of Program Reimbursement (“NPR”) or Revised NPR) or decision that is the subject of the reopening.
Because of the confidentiality of the cost report information, the request should be made by the provider directly. If the provider authorizes another party on behalf of itself to work directly with CGS, the reopening request must include the contact information of the third party. If a reopening request is made directly by a third party, it must include a letter of representation on the provider’s letterhead signed by an authorized contact. The letter of representation must indicate that the designation applies to the specific cost report reopening request. The reopening request will not be considered valid until endorsed by the provider.
CGS will only address material issues on an individual cost report basis in which the cumulative Medicare reimbursement impact for all issues equals or exceeds $10,000. For each issue included in the reopening request, CGS will determine if it meets the criteria of being material as part of the evaluation process. The decision to reopen is made on a case-by-case basis.
New and material evidence, for purposes of reviewing a reopening request, is defined by CGS as evidence that was not available to the provider for inclusion in the initial cost report submission. If evidence was available, CGS expects that the provider should have included that in their initial or amended cost report submission. It is the burden of the provider to support that the new evidence was not available to the provider for inclusion in the initial or amended cost report submission. New analysis performed by the provider on existing documentation will not be grounds for a reopening.
Additionally, CGS defines a "clear and obvious error" as an error in which the evidence that was considered by the MAC in making the determination or decision resulted in an obvious error. Provider errors made on the cost report submission are subject to denial.
A reopening request must include the following for each issue:
- Audit Adjustment Report Number and applicable Workpapers (If applicable).
- Clearly state the issue including the reason for reopening and how, in detail, each issue qualifies for a reopening (new and material evidence; clear or obvious errors and/or inconsistent with the law, regulations and rules ).
- Include the specific requested adjustments to the cost report (i.e., worksheet, line, column and amount)
- Include the estimated Medicare reimbursement dollar impact.
- Include the applicable determination (NPR letter or RNPR) pertaining to this reopening.
- Include applicable supporting documentation.
- For an issue involving a large quantity of documentation, while it is not necessary to supply all support with the reopening request, the complete documentation must be available upon request by CGS.
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