Enrollment Application Denial Decision Tree

Are you a Part B provider?

   

Do you need to know why your application was denied?

   

Click on a Denial Reason to view the description.

Denial Reason 1 - Not in Compliance with Medicare Requirements

The provider or supplier is determined not to be in compliance with the enrollment requirements applicable to its provider or supplier type, and has not submitted a plan of corrective action as outlined in 42 CFR part 488. Such non-compliance includes, but is not limited to, the following situations:

  • Does not submit a hardship exception request and fails to submit the application fee within the prescribed timeframes
  • Submits the fee, but it cannot be deposited into a government-owned account
  • The provider or supplier does not have a physical business address or mobile unit where services can be rendered.
  • The provider or supplier does not have a place where patient records are stored to determine the amounts due such provider or other person.
  • The provider or supplier is not appropriately licensed.
  • The provider or supplier is not authorized by the federal/state/local government to perform the services that it intends to render.
  • The provider or supplier does not meet CMS regulatory requirements for the specialty that it seeks to enroll as.
  • The provider or supplier does not have a valid social security number (SSN) or employer identification number (EIN) for itself, an owner, partner, managing organization/employee, officer, director, medical director, and/or authorized or delegated official.
  • The applicant does not qualify as a provider of services or a supplier of medical and health services. For instance, the applicant is not recognized by any Federal statute as a Medicare provider or supplier. An entity seeking Medicare payment must be able to receive reassigned benefits from physicians in accordance with the Medicare reassignment provisions in Section 1842(b)(6) of the Act (42 U.S.C. 1395u(b)).
  • The provider or supplier does not otherwise meet general enrollment requirements.

Denial Reason 2 - Excluded/Debarred from Federal Program

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 who is required to be reported on the CMS-855 is:

  • Excluded from Medicare, Medicaid, or any other Federal health care program, as defined in 42 CFR Section 1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the Social Security Act, or
  • Debarred, suspended, or otherwise excluded from participating in any other Federal procurement or non-procurement program or activity in accordance with section 2455 of the Federal Acquisition Streamlining Act.

Denial Reason 3 - Felony Conviction

The provider, supplier, or any owner or managing employee of the provider or supplier was, within the preceding 10 years, convicted (as that term is defined in 42 CFR Section 1001.2) of a federal or state felony offense that CMS determines to be detrimental to the best interests of the Medicare program and its beneficiaries. Offenses include, but are not limited in scope and severity to:

  • Felony crimes against persons, such as murder, rape, assault, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions.
  • Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions.
  • Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct.
  • Any felonies outlined in section 1128 of the Social Security Act.

Denial Reason 4 - False or Misleading Information on Application

The provider or supplier submitted false or misleading information on the enrollment application to gain enrollment in the Medicare program.

Denial Reason 5 - On-Site Review/Other Reliable Evidence that Requirements Not Met

Upon on-site review or other reliable evidence, CMS determines that the provider or supplier:

  1. Is not operational to furnish Medicare-covered items or services; or
  2. Otherwise fails to satisfy any Medicare enrollment requirement.

Denial Reason 6 - Existing Overpayment at Time of Application

The enrolling provider, supplier, or owner (as defined in Section 424.502) thereof has an existing Medicare debt.

  1. The enrolling provider, supplier, or owner thereof was previously the owner of a provider or supplier that had a Medicare debt that existed when the latter's enrollment was voluntarily terminated, involuntarily terminated, or revoked, and all of the following criteria are met:
    1. The owner left the provider or supplier with the Medicare debt within 1 year before or after that provider or supplier's voluntary termination, involuntary termination or revocation.
    2. The Medicare debt has not been fully repaid.
    3. CMS determines that the uncollected debt poses an undue risk of fraud, waste, or abuse.

Denial Reason 7 - Medicare Payment Suspension

The current owner (as defined in Section 424.502), physician or non-physician practitioner has been placed under a Medicare payment suspension.

Denial Reason 9 - Hardship Exception Denial and Fee Not Paid

The institutional provider's hardship exception request is not granted, and the institutional provider does not submit the required application fee within 30 days of notification that the hardship exception request was not approved.

Denial Reason 10 - Temporary Moratorium

The provider or supplier submits an enrollment application for a practice location in a geographic area where CMS has imposed a temporary moratorium.

Denial Reason 11 - DEA Certificate/State Prescribing Authority Suspension or Revocation

  1. A physician or eligible professional's Drug Enforcement Administration (DEA) Certificate of Registration to dispense a controlled substance is currently suspended or revoked; or
  2. The applicable licensing or administrative body for any State in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional's ability to prescribe drugs, and such suspension or revocation is in effect on the date the physician or eligible professional submits his or her enrollment application to the Medicare contractor.

Do you want to Submit a Corrective Action Plan (CAP)?

For more information on the definition and requirements of a CAP request, visit the Provider Enrollment Appeals page.

   

Is the postmark date of the denial letter within 30 days from today's date?

   

Is one of the denial reasons listed on the letter due to a felony conviction?

   

A CAP cannot be submitted but you may submit a Reconsideration.

Do you want to Submit a Reconsideration?

For more information on the definition and requirements of a Reconsideration request, visit the Provider Enrollment Appeals page.

   

Is the Postmark date of the letter within 60 days of today's date?

   

Is one of the denial reasons due to a felony?

   

Please contact the Enrollment Contact Center (ECC) at 855-609-9960 or find additional information on the Provider Enrollment page.

The CAP must be received by CMS before the 30th day (from the postmark date of the denial letter) is exceeded. Submit your CAP to:

Centers for Medicare & Medicaid Services
Provider Enrollment & Oversight Group
7500 Security Blvd
Mailstop: AR-18-50
Baltimore, MD 21244-1850

 

The CAP must be received by Noridian before the 30th day (from the postmark date of the denial letter) is exceeded. Mail your CAP to Noridian using the address listed on the letter, or submit it via fax at 701-277-7868

It is too late to submit a reconsideration. However, a reconsideration could be submitted and the hearing officer can review the explanation. The officer will determine whether to accept the late reconsideration request.

The reconsideration must be submitted in writing and received by CMS before the 60 days (from postmark date of the denial letter) is exceeded. Submit your reconsideration to:

Centers for Medicare & Medicaid Services
Provider Enrollment & Oversight Group
7500 Security Blvd
Mailstop: AR-18-50
Baltimore, MD 21244-1850

 

Find additional information regarding the submission of a reconsideration on the Provider Enrollment Appeals page.

The reconsideration must be submitted in writing and received by Noridian before the 60 days (from postmark date of the denial letter) is exceeded. Mail your reconsideration to Noridian using the address listed on the letter.

Find additional information regarding the submission of a reconsideration on the Provider Enrollment Appeals page.

 

Last Updated Oct 16, 2017