§ 422.616 Reopening and revising determinations and decisions.

(a) Subject to paragraph (e) of this section and the rules at § 422.138(c), an organization or reconsidered determination made by an MA organization, a reconsidered determination made by the independent entity described in § 422.592, or the decision of an Administrative Law Judge (ALJ) or attorney adjudicator or the Council that is otherwise final and binding may be reopened and revised by the entity that made the determination or decision, under the rules in part 405 of this chapter. (b) Reopening may be at the instigation of any party. (c) The filing of a request for reopening does not relieve the MA organization of its obligation to make payment or provide services as specified in § 422.618. (d) Once an entity issues a revised determination or decision, any party may file an appeal. (e) If the MA organization approved an inpatient hospital admission under the rules at § 412.3(d)(1) and (3) of this chapter, any additional clinical information obtained after the initial organization determination cannot be used as new and material evidence to establish good cause for reopening the determination.