Appeals Process

When billing privileges have been denied or revoked, the applicant/supplier has two options available to contest the determination. The applicant/supplier may in most instances submit a Corrective Action Plan (CAP) or submit a request for reconsideration. When submitting your request, please keep in mind the following:

• The applicant/supplier must submit a CAP within 35 days from the postmark of the denial or revocation letter
• The request for reconsideration must be made within 65 days from the postmark of the denial or revocation letter
• The request must have the signature of the authorized official, owner or partner on file  

Note: According to Pub 100-8, Chapter 15, Section 25 a provider or supplier that is denied enrollment in the Medicare program or whose billing privileges have been revoked cannot submit a new enrollment application until the following has occurred:

• If the denial was not appealed, the provider or supplier may reapply after its appeal rights have lapsed
• If the denial was appealed, the provider or supplier may reapply after it has received notification the determination was upheld
• If the revocation is not overturned and all appeal options are exhausted, the supplier must wait the enrollment bar as specified in the revocation letter

CAPs
The CAP is to ensure the business, at the location in question, is in compliance with the current supplier standards (42CFR424.57). Submission of a CAP shall contain, at a minimum, verifiable evidence of compliance and the sufficient assurance of the intent to comply fully with the supplier standards in the future.

The CAP and the acceptability of the plan is negotiated between the NSC/CMS and the applicant/supplier (42CFR422.57(d)). However, it is important to note that denials and revocations are generally based on noncompliance with the Supplier Standards. Being in compliance is non-negotiable.

If the NSC/CMS is satisfied the issues of noncompliance have been resolved, billing privileges may be issued or reinstated. If the applicant has been denied, the effective date of the billing privileges will be the day the NSC releases the number (1834 J of the Social Security Act and 42CFR422.57). If revoked, reinstatement will be effective the date CMS approves the CAP and the supplier has been determined to be in compliance with the supplier standards.

If the NSC/CMS upholds either a denial or a revocation, the applicant/supplier may request a reconsideration. Please note this request must be made within 65 days from the postmark of the letter issuing the initial determination, and not 65 days from the letter upholding the denial or revocation.

When a CAP Won’t Fit

Pursuant to 424.535(a)(5), if CMS determines, upon on-site review, that the provider or supplier is no longer operational to furnish Medicare covered items or services, or is not meeting Medicare enrollment requirements under statute or regulation to supervise treatment of, or to provide Medicare covered items or services for, Medicare patients. Upon on-site review, CMS determines that—

Provider or supplier conduct. The provider or supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier is—
(i) Excluded from the Medicare, Medicaid, and any other Federal health care program (ii) Is debarred, suspended, or otherwise excluded from participating in any other Federal procurement or non-procurement program or activity;

Felonies. The provider, supplier, or any owner of the provider or supplier, within the 10 years preceding enrollment or revalidation of enrollment, was convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries;

On-site review. CMS determines, upon on-site review, that the provider or supplier is no longer operational to furnish Medicare covered items or services, or is not meeting Medicare enrollment requirements under statute or regulation to supervise treatment of, or to provide Medicare covered items or services for, Medicare patients. Upon on-site review, CMS determines that the supplier is non-operational.
 
When revoked for the aforementioned reasons, the supplier’s only recourse is to submit a reconsideration request. More specific detail can be found at 424.535(a) (1), (a) (2), (a) (3), and (a) (5).

Reconsiderations
If you feel the NSC has made a factual mistake or the noncompliance issue has been corrected, the supplier may submit a reconsideration request. A reconsideration request is specifically for an on-the-record hearing before a Hearing Officer (HO) not involved in the initial decision to deny or revoke billing privileges. If you have any questions regarding this information, please contact the NSC Customer Line at 866-238-9652.

DMEPOS suppliers choosing to appeal a Medicare denial or revocation are encouraged to use the Hearings and Appeals checklist when submitting documentation for review. Suppliers are still required to submit a detailed cover letter specifying the request of reconsideration or a CAP. The checklist should be submitted along with the CAP/reconsideration packet.