Provider Enrollment Reconsiderations, CAPs, and Rebuttals

Overview

A provider or supplier whose Medicare enrollment is denied or whose Medicare billing has been revoked may appeal Provider Enrollment's decision. Effective date determinations, change of information request denials and reassignment denials may also be appealed. The requests must be started within 35 to 65 days from the date of the denial or revocation letter. There are two types of submissions; Corrective Action Plans (CAP) and Reconsideration Requests. All CAPs and Reconsiderations for Part A suppliers should be submitted to CMS.

A provider or supplier whose Medicare enrollment is deactivated may have the right to file a rebuttal and challenge their deactivation. Providers are given this opportunity to demonstrate that they meet all applicable enrollment requirements and that their Medicare billing privileges should not have been deactivated.

Reconsideration (Appeal)

The Reconsideration Process allows a provider/supplier to appeal the decision of their billing privileges being denied or revoked. Reconsideration requests must be submitted in the form of a letter.

Reconsideration Coversheet

  • Must be submitted within 65 days from date of denial or revocation notice.
  • Reconsiderations can be mailed or emailed. This information is on the denial or revocation notice.
  • Must contain signature from provider, authorized/delegated official or a legal representative of provider.
  • If signed by an attorney or legal representative, a statement of authorization needs to accompany the reconsideration giving that individual the right to represent the provider.

Once the appeal is received, a determination will be issued within 90 days. A decision letter will be mailed at this time.

Rejected or Returned Reconsideration

A dismissed reconsideration holds no further appeal rights. If the reconsideration is found unfavorable, higher appeal rights do exist. See the appeal decision letter for details on higher appeal options.

Corrective Action Plan (CAP)

The CAP Process gives a provider/supplier an opportunity to correct deficiencies (if possible) that resulted in the denial of an application or billing privileges being denied or revoked. A CAP must be submitted in the form of a letter.

CAP coversheet

  • Must be submitted within 35 days from date of denial or revocation notice.
  • Provide verifiable evidence provider/supplier is in compliance with Medicare requirements.
  • CAPs can be mailed or emailed. This information is on the denial or revocation notice.
  • Must contain signature from provider, authorized/delegated official or a legal representative of provider.
  • If signed by an attorney or legal representative, a statement of authorization needs to accompany the reconsideration giving that individual the right to represent the provider.

Once the appeal is received, a CAP will be processed within 60 days. A decision letter will be mailed at this time.

Rejected or Returned CAP

A dismissed CAP holds no further appeal rights.

This is the process if you have submitted both a CAP and a reconsideration:

  • The CAP will have a determination made first.
  • If the CAP is found favorable, please withdraw your reconsideration.
  • If the CAP is found unfavorable, you will not have higher appeal rights as an unfavorable CAP decision may not be appealed.
  • The reconsideration will then be reviewed, and a determination made.

If you receive an unfavorable CAP decision and did not submit a reconsideration during the time of the CAP review, you may still submit a reconsideration for review, if within the allowable 65 day timeframe of the initial determination letter. See the appeal decision letter for addition details regarding a CAP.

Rebuttal Process

Rebuttals give providers or suppliers the opportunity to demonstrate that their Medicare billing privileges should not have been deactivated. These requests can be mailed or emailed to Noridian.

A Rebuttal Coversheet may be used.

  • Must be submitted within 15 calendar days from the date of the deactivation notice. Any rebuttal submitted after the 15 days will be dismissed.
  • Must provide specific reasons for the rebuttal as well as all supporting documentation that supports the rebuttal reason.
  • May only submit one rebuttal in response to a deactivation.
  • Signed by the individual provider, authorized/delegated official or a legal representative.
  • If the rebuttal submission is signed by an attorney or legal representative, a written statement saying they have the authority to represent the provider/supplier must accompany the rebuttal submission. 
  • Fax number and address are located at bottom of the rebuttal cover sheet.
  • Include a valid email address if communication via email is preferred.

If the correct signature is not sent with the rebuttal, we send a request for that information. If we ask for a missing signature statement or appointment statement, the information must be received in 15 days.

If your rebuttal is found favorable but additional information is required to reactivate your enrollment, we will send a request for that information and require that information within 30 days.

Deactivation Reasons for Rebuttals

Only enrollments that are deactivated for the following reasons can be challenged through the rebuttal process.

  • Deactivation because the provider/supplier does not submit any Medicare claims for 12 consecutive calendar months.
  • Deactivation because the provider/supplier does not report a change to the information supplied on the enrollment application with the applicable time period of 90 days.
  • Deactivation because the provider/supplier does not furnish complete and accurate information and all supporting documentation or resubmit and certify to the accuracy of its enrollment information.
  • Deactivation because the provider/supplier is not in compliance with all enrollment requirements.
  • Deactivation because the provider’s/supplier’s practice location is non-operational or otherwise invalid.
  • Deactivation because the provider/supplier is deceased.
  • Deactivation because the provider/supplier is voluntarily withdrawing from Medicare.
  • Deactivation because the provider is the seller in an HHA change of ownership under § 424.550(b)(1).

 

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