Title 42

SECTION 425.315

425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.

§ 425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.

(a) Reopenings. (1) If CMS determines that the amount of shared savings due to the ACO or the amount of shared losses owed by the ACO has been calculated in error, CMS may reopen the initial determination or a final agency determination under subpart I of this part and issue a revised initial determination:

(i) At any time in the case of fraud or similar fault as defined in § 405.902; or

(ii) Not later than 4 years after the date of the notification to the ACO of the initial determination of savings or losses for the relevant performance year under § 425.604(f), § 425.605(e), § 425.606(h), § 425.609(e) or § 425.610(h), for good cause.

(2) Good cause may be established when -

(i) There is new and material evidence that was not available or known at the time of the payment determination and may result in a different conclusion; or

(ii) The evidence that was considered in making the payment determination clearly shows on its face that an obvious error was made at the time of the payment determination.

(3) A change of legal interpretation or policy by CMS in a regulation, CMS ruling or CMS general instruction, whether made in response to judicial precedent or otherwise, is not a basis for reopening a payment determination under this section.

(4) CMS has sole discretion to determine whether good cause exists for reopening a payment determination under this section.

(b) [Reserved]

[81 FR 38013, June 10, 2016, as amended at 83 FR 60092, Nov. 23, 2018; 83 FR 68068, Dec. 31, 2018]

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