Provider Enrollment Reconsiderations, CAPs, and Rebuttals - JF Part B

A provider or supplier who is dissatisfied with an initial determination may challenge the determination through the submission of an appeal. The initial determination letter will provide the information as to where to send your appeal. The types of initial determinations that can be appealed are listed below.

1. The denial of enrollment in the Medicare program.
2. The revocation of a provider’s or supplier’s Medicare billing privileges.
3. The effective date of participation in the Medicare program.

There are two types of appeals that can be submitted. The initial determination letter will instruct you as to what type of appeal you are entitled to submit.

1. Reconsideration - allows the provider or supplier an opportunity to demonstrate that an error was made in the initial determination at the time the initial determination was implemented. A reconsideration request does not allow a provider or supplier the opportunity to correct the deficiencies that led to the initial determination. A decision will be rendered within 90 days from receipt of the valid reconsideration.
2. Correction Action Plan (CAP) - the opportunity to demonstrate compliance with all applicable Medicare requirements by correcting the deficiencies (if possible) that led to the initial determination. A CAP may only be submitted regarding either a denial or revocation for non-compliance. A decision will be rendered within 60 days from receipt of the valid CAP.

You may submit a CAP and a Reconsideration simultaneously. The CAP will be reviewed first and if denied (found unfavorable) or does not satisfy all the requirements of the initial determination, the reconsideration request will then be processed.

Reconsideration Requirements

A Reconsideration Coversheet may be used

• Must be submitted within 65 days from the date on the initial determination letter.
• Must contain, at a minimum, state the issues, or the findings of facts with which the affected party disagrees, and the reasons for the disagreement.
• Should include all documentation and information the provider or supplier would like to be considered in reviewing the reconsideration request.
• Reconsiderations can be mailed or emailed. This information can be found on the initial determination letter.
• Must be in the form of a letter that is signed by the provider, authorized/delegated official or a legal representative.
  • An authorized/delegated official for groups cannot sign and submit a reconsideration request on behalf of a reassigned provider without the provider submitting a signed statement authorizing that individual from the group to act on his/her behalf.
  • If the representative is an attorney, the attorney must include a statement that he/she has the authority to represent the provider or supplier. If the representative is not an attorney, the provider/supplier must file written notice of the appointment of a representative.
  • The provider’s/supplier’s contact person does not qualify as a “representative” for purposes of signing a reconsideration request without the requisite appointment statement and signature by the individual provider or supplier.

Corrective Action Plan (CAP) Requirements

CAPS may ONLY be submitted for denials under 42 CFR §424.530(a)(1) and revocations under 42 CFR §424.535(a)(1)

• A CAP Coversheet may be used.
• Must be submitted within 35 days from the date on the initial determination letter.
• Must contain, at a minimum, verifiable evidence that the provider/supplier is in compliance with all applicable Medicare requirements.
• Should include all documentation and information the provider/supplier would like to be considered in reviewing the CAP.
• CAPs can be mailed or emailed. This information can be found on the initial determination letter.
• Must be in the form of a letter that is signed by the provider, authorized/delegated official or a legal representative.
  • An authorized/delegated official for groups cannot sign and submit a CAP request on behalf of a reassigned provider without the provider submitting a signed statement authorizing that individual from the group to act on his/her behalf.
  • If the representative is an attorney, the attorney must include a statement that he/she has the authority to represent the provider or supplier. If the representative is not an attorney, the provider/supplier must file written notice of the appointment of a representative.
  • The provider’s/supplier’s contact person does not qualify as a “representative” for purposes of signing a CAP request without the requisite appointment statement and signature by the individual provider or supplier.

Further Appeal Rights

• A dismissed CAP/Reconsideration does not offer further appeal rights.
• A denied (Unfavorable) CAP does not offer further appeal rights.
• An unfavorable Reconsideration does offer further appeal rights.
  • This information can be found on the decision letter.

Provider Enrollment Rebuttals

A provider or supplier whose Medicare billing privileges have been deactivated may file a rebuttal. A rebuttal is an opportunity for the provider or supplier to demonstrate that it meets all applicable enrollment requirements and that Medicare billing privileges should not have been deactivated. The deactivation letter will list where to submit your rebuttal. The types of deactivations that allow the submission of a rebuttal are found under 42 CFR §424.540(a) and are listed below. A decision will be rendered within 30 days of receipt of a valid rebuttal.

Rebuttal Requirements

A Rebuttal Coversheet may be used.

• Must be submitted within 15 calendar days from the date of the deactivation notice.
• May be mailed, emailed, or faxed.
• Must specify the facts or issues with which the provider/supplier disagrees, and the reason for the disagreement.
• Should include all documentation and information the provider/supplier would like to be considered in reviewing the deactivation.
• Must be in the form of a letter that is signed and dated by the provider, authorized/delegated official or a legal representative.
  • If the representative is an attorney, the attorney must include a statement that he/she has the authority to represent the provider or supplier. If the representative is not an attorney, the provider/supplier must file written notice of the appointment of a representative. This notice of appointment must be signed and dated by the individual provider or supplier, the authorized or delegated official, or a legal representative.

Rebuttal decisions are final and are not offered further rebuttal rights or appeal rights.

Deactivation Reasons for Rebuttals

• The provider/supplier does not submit any Medicare claims for 12 consecutive calendar months.
• The provider/supplier does not report a change to the information supplied on the enrollment application with the applicable time period of 90 days.
• 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.
• The provider/supplier is not in compliance with all enrollment requirements.
• The provider’s/supplier’s practice location is non-operational or otherwise invalid.
• The provider/supplier is deceased.
• The provider/supplier is voluntarily withdrawing from Medicare.