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Rejection of Application Contractor provides Notice of rejected application, including reason(s) forrejection and how to reapply Rejected or returned applications are treated as non-applications No appeal rights from a rejection Can be a problem when the receipt date of the application establishes the“effective billing date.”
Reasons for Rejection No signature on 855 applicationApplication contains a copied or stamped signatureSignature on application is not datedCMS 855I was signed by someone other than the individual practitioner orCMS 855B, 855R, 855S, or 855A was signed by someone other than anauthorized official Outdated version of application submitted For medical group practices, applicant failed to submit all of the formsnecessary to process the reassignment Must submit 855I if not yet enrolled Initial 855B must be accompanied by at least one 855R
Reasons for Rejection Part A Change of Ownership (CHOW) applications submitted more than 3months before anticipated date of sale listed Part B supplier applications received more than 30 days prior to effectivedate listed on application CMS application not needed (Ex. 855I submitted with an 855R to reassign toa new group when there are no changes to the 855I application) CMS 588 sent without signature, date, or with a copied signature Missing information not submitted within 30 days of request Application fee not submitted
Practice Tips Always report changes timely Physicians should complete an 855I change of information to update theircorrespondence address when reassigning to new groups Physicians should submit an 855R application to terminate an oldreassignment or an individual practice PTAN Timely respond to development requests – if the contractor follows up on arequest, it does not restart the 30-day clock (discretion to extend) If a rejection is wrong, then contact a Provider Enrollment Manager orDirector and explain why the MAC’s rejection is erroneous and request thatthey re-accept the application with the original submission date (billing timeat stake)
Denial of Application According to the PIM, if the contractor finds a legal basis for denial (and, ifapplicable, receives approval from the Provider Enrollment Oversight Group(PEOG)), the contractor shall deny the application Denial letter must contain: Legal (regulatory) basis for denial Clear explanation of why application is being denied, including the facts orevidence relied upon in making the decision Explanation of why the provider does not meet the enrollment criteria Procedures for submitting a Corrective Action Plan (CAP) if applicable Information regarding further appeal rights
Reasons for Denial1) Not in Compliance with Medicare Requirements No physical address; not appropriately licensed2) Excluded to Debarred from Federal Programs Provider or supplier, or any owner, managing employee, authorized ordelegated official, medical director, supervising physician, or other health careor administrative or management services personnel (such as a billingspecialist, accountant, or human resources specialist) furnishing servicespayable by a federal health care program3) Felony Conviction Within the Past 10 Years Provider, supplier, or any owner or managing employee
Reasons for Denial4) False or Misleading Information5) On-site Review Not operational to furnish Medicare-covered services or otherwise fails tosatisfy any Medicare enrollment requirement6) Existing Overpayment Ex: Dr. X, a sole proprietor, has a 70,000 overpayment. Three months later,he joins Group Y and becomes a 50 percent owner of the practice. Group Ysubmits an initial enrollment application. Group Y’s enrollment could be deniedbecause Dr. X is an owner.7) Medicare or Medicaid Payment Suspension Provider, supplier or any owning and managing employee or organization of theprovider or supplier is currently under a Medicare or Medicaid payment
Reasons for Denial8) Home Health Capitalization HHA cannot furnish (within 30 days of contractor’s request) supportingdocumentation to verify that the HHA meets the initial operating fundsrequirement9) Hardship Exception Denial and Fee Not Paid An institutional provider’s hardship exception request is not granted andprovider fails to submit the required fee within 30 days10) Temporary Moratorium Provider or supplier submits an enrollment application for a practice location ina geographic area where CMS has imposed a temporary moratorium11) DEA Certificate/State Prescribing Authority Suspension or Revocation DEA certificate suspended or revoked State license to practice/prescribe
Reasons for Denial12) Revoked Under a Different Name, Numerical Identifier, or Business Entity Any evidence indicating that the two parties [the revoked provider/supplier andthe newly enrolling provider/supplier] are similar or that the provider or supplierwas created to circumvent the revocation or reenrollment bar13) Affiliation that Poses an Undue Risk14) Other Program Termination or Suspension Medicaid termination or suspension License revoked in another state15) Patient Harm
When PEOG Approval is Necessary Felony convictionsFalse or misleading information or applicationExisting overpayment at time of applicationRevoked under different name, numerical identifier, or business identityaffiliation that poses an undue risk Other program termination or suspensionPEOG will also instruct the contractor whether a reapplication bar is to beimposed
Post-Denial Submissionof Enrollment ApplicationA denied provider may not submit a new application until: If the initial denial was not appealed, the provider’s appeal rights have lapsed If the initial denial was appealed, the provider has received notification that thedetermination was upheld; The reapplication bar has expired, if applicable
But If the denial was due to adverse activity (e.g., exclusion, felony) of an owner,managing employee, an authorized or delegated official, medical director,supervising physician, or other health care or administrative or managementpersonnel of the provider or supplier furnishing services payable by a federalhealth care program, the denial may be reversed (with PEOG approval) if theprovider or supplier submits proof that it has terminated its businessrelationship with that individual or organization within 30 days of the denialnotification.
Denial of RevalidationIf the contractor denies a revalidation application, the contractor shall – unlessan existing CMS instruction or directive states otherwise - deactivate theprovider’s Medicare billing privileges if the applicable time period for submittingthe revalidation application has expired. If it has not expired, the contractorshall deactivate the provider’s billing privileges after the applicable time periodexpires unless the provider has resubmitted the revalidation application.
DeactivationMACs may deactivate a provider number for the following reasons: Failure to submit a claim for 12 calendar months Failure to report a change within 90 days (e.g. change of practice location, changeof managing employee, change of billing service) Failure to report change of ownership within 30 days Failure to submit missing information after 30 days following requestNOTE: There are no appeal rights for deactivation. . . but possible argument concerning the effective date of billing privileges
Part A v. Part B Deactivation Deactivation does not affect the Participation Agreement To reactivate a Part A billing number, the provider must file a 855Aapplication – the existing provider number is reactivated and the billingprivileges are restored without affecting the “effective billing date” To reactivate a Part B billing number (except DMEPOS, ASC, or portableX-ray), submit the appropriate application and the old PTAN numbers will beterminated and new PTAN numbers will be issued In most cases the new PTAN will have an effective billing date that is the laterof the first day services were provided at the location or 30 days before the newapplication was received by the MAC
DMEPOS To reactivate billing privileges for a DMEPOS supplier, submit the 855Sapplication and obtain approval from the National Supplier Clearinghouse(NSC), show proof of accreditation, undergo a site visit The effective billing date will be after all of these steps have been completedwhich may be many months
Revocation Removal of billing privileges and termination of provider agreement Can be retroactive Revocations have been occurring more frequently and the re-enrollment barimposed is longer Reasons similar to denial, but more of them
Reasons for Revocation NoncomplianceProvider or Supplier Conduct (Excluded, Suspended, Debarred)Felony ConvictionFalse of Misleading InformationOn-Site Review – not operational; fails to meet any enrollment requirementGrounds Related to Provider and Supplier Screening Requirements Application fee not submitted; hardship exception not granted and providerdoes not submit applicable application or fee within 30 days; CMS cannotdeposit application amount; provider or supplier lacks sufficient funds to pay theapplication fee
Reasons for Revocation Misuse of Billing Number Provider or supplier knowingly sells or allows another individual to use its billingnumber Not valid reassignment or CHOW Abuse of Billing Privileges Essentially fraud (decreased beneficiary; physician not in the state or countrywhere services were furnished; equipment required for testing not present) Pattern or practice of submitting claims that fail to meet Medicare requirements Failure to Report Change in ownership Adverse legal action Change in practice location
Reasons for Revocation Failure to Maintain Documentation or Provide Access Must maintain documentation for 7 years from date of service Must provide access to documentation upon request Failure to Substantiate Initial Reserve Operating Funds (HHA) Other Program Termination Prescribing Authority DEA certificate suspended, revoked, or surrendered in response to an order toshow cause Licensing authority suspends or revokes ability to prescribe
Reasons for Revocation Improper Prescribing Practices Pattern or practice is abusive or represents a threat to the health and safety ofbeneficiaries or both Existing Debt to CMS Revoked Under Different Name, Numerical Identifier, or Business Entity
Reasons for Revocation Affiliation that Poses an Undue Risk Billing from Non-Compliant Location CMS may revoke a provider’s or supplier’s enrollment (even if all of thepractice locations comply with the enrollment requirements) if the provider orsupplier billed for services performed at or items furnished form a location that itknew or should have known did not comply with enrollment requirements Abusive Ordering, Certifying, Referring, or Prescribing Do the diagnoses support the orders, certifications, referrals or prescriptions? Could the necessary evaluation not have occurred? Patient Harm
Revocation Effective Dates Prospective 30 days after CMS (or contractor) mails notice of its determination to theprovider or supplier Retroactive Date of felony convictionDate of exclusionDate of license suspension or revocationDate practice location was determined not to be operational
Submission of Claims Furnished Before Revocation Must submit all claims for items and services furnished before the effectivedate of the revocation within 60 days A revoked HHA must submit all claims within 60 days of the later of Effective date of the revocation The date the HHA’s last payable episode ends
Extension of RevocationIf a provider’s or supplier’s Medicare enrollment is revoked, CMS may revokeany and all of the provider's or supplier's Medicare enrollments, including thoseunder different names, numerical identifiers or business identities and thoseunder different types.
Revocation Based on Voluntary TerminationCMS may revoke a provider's or supplier's Medicare enrollment if CMSdetermines that the provider or supplier voluntarily terminated its Medicareenrollment in order to avoid a revocation.
Dealing with the MAC Even if there is an error, the MAC is not usually in a position to fix theproblem without going through the official processes (CAP, Reconsideration) Be aware of the deadlines to submit a CAP or to Request Reconsideration Sometimes the advice of the MAC is wrong MAC told a group of APRNs that the group had to be established before theAPRNs could file 855R applications. The group was established and then the855R applications were filed. This resulted in a gap in the APRNs being able tobill – could only bill 30 days prior to applications being filed. The evidence ofthe MAC giving the wrong advice was not persuasive in getting thereassignment dates reset to be the effective as the same date of the group. Gov. CMS, CR 2136 (May 21, 2010)
Corrective Action Plans Must submit evidence to prove that you are in compliance CAPs are only available for Denials under 42 CFR 530(a)(1) - Noncompliance Revocations under 42 CFR 535(a)(1) – Noncompliance Only one opportunity to correct all deficiencies that served a basis for theinitial determination Must be signed by the provider or supplier, an authorized or delegatedofficial (as reported in enrollment record), or attorney Must be received in writing within 35 calendar days of the date of the denialor revocation letter Deadline to Request Reconsideration not tolled
Requests for Reconsideration Available for all denials and revocations Must be received within 65 days calendar days of the date of the denial orrevocation letter Must be signed by the provider or supplier, an authorized or delegatedofficial (as reported in enrollment record), or attorney Must state the issues of fact with which provider or supplier disagrees andstate the reasons for disagreement Only opportunity to submit evidence that may have a bearing on the decision ALJs very rarely allow additional information to be submitted
Levels of Appeal Request for Reconsideration Request for ALJ Hearing Identify specific issues as well as the findings of fact and conclusions of lawwith which the provider or supplier disagrees Specify the basis for contending the findings and conclusions are incorrect Request for Department Appeals Board (DAB) review Specify the issues, the findings of fact and conclusions of law with which theparty disagrees Specify the basis for contending the findings and conclusions are incorrect Judicial Review of DAB Decision Only available to provider or supplier
Preclusion List Took effect January 1, 2019 Comprised of any individual or entity that meets the following criteria: Currently revoked or under an active reenrollment bar Have engaged in behavior for which CMS could have revoked if they had beenenrolled in Medicare Convicted of a felony within the previous 10 years that CMS deems detrimentalto the best interests of the Medicare program List available to Medicare Advantage Plans and Part D Plans MA Plans will deny payment for a health care item or service furnished by anindividual or entity on the Preclusion List Part D plans will reject pharmacy claims or deny a beneficiary’s request forreimbursement for a Part D drug that is prescribed by an individual on thePreclusion List
Preclusion List Providers notified by email and follow-up letter (based on enrollment record) CMS was still catching up this past summer Mistakes made – physician received notice that should have been sent toanother physician Provider may appeal inclusion on the list, but not underlying reason forrevocation, exclusion, or other adverse action that led to inclusion on the list Length of Preclusion Length of the re-enrollment bar If based on a felony conviction, for 10 years from the date of the conviction,unless CMS determines that a shorter length of time is warranted (Eff.1/1/2020)
CMS 855I was signed by someone other than the individual practitioner or CMS 855B, 855R, 855S, or 855A was signed by someone other than an . then contact a Provider Enrollment Manager or . satisfy any Medicare enrollment requirement 6) Existing Overpayment Ex: Dr. X, a sole proprietor, has a 70,000 overpayment. .
