BASIC (02-82)

A determination or decision may be reopened at any time if it was procured by fraud or similar fault, regardless of whether criminal prosecution has been or will be instituted. The fraud or similar fault may be that of the beneficiary, provider, physician, or any other person.

“Similar fault” means (A) an act which approximates fraud; i.e., the furnishing of information which the individual knew was incorrect or incomplete, or the deliberate concealment of information, without a judicial finding of fraud, or (B) an established pattern of billing for excessive or noncovered services, including services not medically reasonable and necessary or custodial care.