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Provider Enrollment Appeals Process

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A provider or supplier whose Medicare enrollment is denied or whose Medicare billing has been revoked may appeal Provider Enrollment's decision.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 30 to 60 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.

Reconsideration (Appeal)

The Reconsideration Process allows a provider/supplier to appeal the decision of their billing privileges being denied or revoked. Requests must be submitted, by mail, in writing within 60 days from the date of the notification/determination letter.

  • Reconsiderations must be mailed to address on the denial or revocation notice.
  • Must contain signature from provider, authorized/delegated official or a legal representative of provider.
  • Signature from a contact person listed on an enrollment application is not accepted.

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 rejected or returned Reconsideration holds no further appeal rights. But 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 by fax or mail.

  • Must be submitted within 30 days from date of denial or revocation notice
  • Provide verifiable evidence provider/supplier is in compliance with Medicare requirements
  • Signed and dated by provider, authorized/delegated official or a legal representative
  • Fax number and address are located at bottom of form
  • Signature from a contact person listed on an enrollment application is not accepted

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 rejected or returned 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. See the appeal decision letter for addition details regarding a CAP.

 

Last Updated Mar 30, 2017