Provider Enrollment Corrective Action Plan (CAP), Reconsideration, and Rebuttal Decision Tree

The Provider Enrollment Corrective Action Plan (CAP), Reconsideration, and Rebuttal Decision Tree is a tool that may assist the user in submitting a Provider Enrollment reconsideration request, corrective action plan or rebuttal. The user will be provided a short series of questions to determine what type of submission they may be eligible for and where to send their submission.

Disclaimer: Refer to the initial determination or deactivation letter for applicable corrective action plan, reconsideration request or rebuttal rights, submission requirements, and address information.

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Q0

Are you a Part B Provider?

   
Q1 Q0N

Are you appealing a deactivation?

   
Q2 Q1Y

Rebuttals can only be submitted for the following deactivation reasons:

  • Non-response to a revalidation request
  • Failure to report a change
  • Non-billing
  • No valid practice location for 90 days

Were you deactivated for one of these reasons?

   
Q3 Q1N

Are you appealing a rejected or returned application?

   
Q4 Q2Y

A rebuttal must be received within 20 days from the date of the deactivation letter.

Is the date on the letter more than 20 calendar days ago?

   
Q2N DE

You do not have rebuttal rights.

Contact the Provider Enrollment Contact Center for assistance.

Q3Y DE

Rejected and returned applications do not have appeal rights.

Q5 Q3N

The following supplier types submit their appeals to CMS:

  • Ambulatory Surgical Centers
  • Independent Laboratories (CLIA Lab)
  • Mammography Screening Centers
  • Portable X-Ray Suppliers
  • Independent Diagnostic Testing Facilities
  • Opioid Treatment Programs
  • Medicare Diabetes Prevention Programs

Are you one of those supplier types?

   
Q4Y DE

Your rebuttal rights have expired. You may reactivate your Medicare enrollment.

Q4N DE

You may submit a rebuttal.

Q5Y DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q6 Q5N

Are you one of the following supplier types?

  • Mass Immunization/Flu Roster Biller
  • Ambulance Service Supplier
  • Intensive Cardiac Rehabilitation
  • Radiation Therapy Center
  • Pharmacy
   
Q7 Q6Y

Were you revoked?

   
Q8 Q6N

Are you appealing a revocation or denial decision?

   
Q9 Q7Y

Were you revoked for non compliance?

   
Q10 Q7N

Were you denied?

   
Q11 Q8Y

Do you want to submit information to correct the deficiency that caused the revocation or denial?

   
Q12 Q8N

Are you appealing an effective date or billing lapse?

   
Q13 Q9Y

A CAP must be received within 35 days from the date of the denial letter.

Is the date on the letter more than 35 calendar days ago?

   
Q14 Q9N

You do not have CAP rights.

Do you want to submit a reconsideration?

   
Q15 Q10Y

Do you want to submit information to correct the deficiency that caused a denial?

   
Q16 Q10N

Are you appealing an effective date or billing lapse?

   
Q17 Q11Y

A CAP must be received within 35 days from the date of the denial letter.

Is the date on the letter more than 35 calendar days ago?

   
Q18 Q11N

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q19 Q12Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q20 Q12N

Are you appealing an Opt Out Period?

   
Q21 Q13Y

Your CAP rights have expired.

Do you want to submit a reconsideration?

   
Q13N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q22 Q14Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q14N DE

Contact the Provider Enrollment Contact Center for assistance.

Q23 Q15Y

A CAP must be received within 35 days from the date of the denial letter.

Is the date on the letter more than 35 calendar days ago?

   
Q24 Q15N

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q25 Q16Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q16N DE

Contact the Provider Enrollment Contact Center for assistance.

Q26 Q17Y

You do not have CAP rights.

Do you want to submit a reconsideration?

   
Q27 Q17N

Was the revocation or denial for non-compliance?

   
Q18Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q28 Q18N

Were you denied for only the following:

  • Non-compliance
  • False or misleading information
  • Failed on-site review
  • Payment suspension
  • Initial reserve operating funds
  • Application fee/hardship exception
  • Temporary moratorium
   
Q19Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q19N DE

Submit a reconsideration to Noridian.

Q20Y DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q20N DE

Contact the Provider Enrollment Contact Center for assistance.

Q29 Q21Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q21N DE

Contact the Provider Enrollment Contact Center for assistance.

Q22Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q22N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q30 Q23Y

Your CAP rights have expired.

Do you want to submit a reconsideration?

   
Q31 Q23N

Were you denied for non-compliance?

   
Q24Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q32 Q24N

Were you denied for only the following:

  • Non-compliance
  • False or Misleading Information
  • Failed On-Site Review
  • Payment Suspension
  • Initial Reserve Operating Funds
  • Application Fee/Hardship Exception
  • Temporary Moratorium
   
Q25Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q25N DE

Submit a reconsideration to Noridian.

Q33 Q26Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q26N DE

Contact the Provider Enrollment Contact Center for assistance.

Q27Y DE

Submit a CAP to Noridian. Only the denial or revocation reason of non-compliance will be reviewed.

Q35 Q27N

You do not have CAP rights.

Do you want to submit a reconsideration?

   
Q28Y DE

Submit a reconsideration to Noridian.

Q36 Q28N

Were you revoked for only the following:

  • Non Compliance
  • On-site review
  • Grounds related to provider and supplier screening requirements
  • Failure to Report
   
Q29Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q29N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q37 Q30Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q30N DE

Contact the Provider Enrollment Contact Center for assistance.

Q31Y DE

Submit a CAP to Noridian. Only the denial reason of non-compliance will be reviewed.

Q31N DE

You do not have CAP rights.

Contact the Provider Enrollment Contact Center for assistance.

Q32Y DE

Submit a reconsideration to Noridian.

Q32N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q33Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q33N DE

Submit a reconsideration to Noridian.

Q38 Q35Y

A reconsideration must be received within 65 days from the date of the initial determination letter.

Is the date on the letter more than 65 calendar days ago?

   
Q35N DE

Contact the Provider Enrollment Contact Center for assistance.

Q36Y DE

Submit a reconsideration to Noridian.

Q36N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q37Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q39 Q37N

Were you denied for only the following:

  • Non-compliance
  • False or Misleading Information
  • Failed On-Site Review
  • Payment Suspension
  • Initial Reserve Operating Funds
  • Application Fee/Hardship Exception
  • Temporary Moratorium
   
Q38Y DE

Your reconsideration rights have expired.

Contact the Provider Enrollment Contact Center for assistance.

Q40 Q38N

Were you denied for only the following:

  • Non-compliance
  • False or Misleading Information
  • Failed On-Site Review
  • Payment Suspension
  • Initial Reserve Operating Funds
  • Application Fee/Hardship Exception
  • Temporary Moratorium
   
Q39Y DE

Submit a reconsideration to Noridian.

Q39N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Q40Y DE

Submit a reconsideration to Noridian.

Q41 Q40N

Were you revoked for only the following:

  • Non-compliance
  • On-site review
  • Grounds related to provider and supplier screening requirements
  • Failure to Report
   
Q41Y DE

Submit a reconsideration to Noridian.

Q41N DE

Submit your appeal to CMS using the CMS CAP Reconsideration Coversheet.

Last Updated Wed, 16 Dec 2020 18:00:27 +0000