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CMS Updates Enrollment Decision Appeals Procedure

Posted on Monday, February 10, 2020 1:46 PM

CMS has updated Chapter 15 – Medicare Enrollment –  of the Medicare Program Integrity Manual via Change Request (CR) 11210/Transmittal 936 Provider Enrollment Appeals Procedure. This CR addresses provider enrollment appeals and provides instructions to the Medicare Administrative Contractor (MAC) on how to handle reconsideration requests and Corrective Action Plans (CAP) for decisions.  The effective date for the changes is May 1, 2020.

Providers and suppliers can submit a CAP and reconsideration request if enrollment is denied for noncompliance with the enrollment requirements for the applicable provider or supplier type and if the provider or supplier has not submitted a CAP.  Only if enrollment is denied for noncompliance, the provider/supplier may only submit a reconsideration request.

“The CAP is an opportunity for the provider or supplier to demonstrate it has corrected the deficiencies identified in an enrollment denial and establish eligibility to enroll in the Medicare program. CAPs may also be submitted in the case of the revocation of billing privileges. Providers and suppliers have 35 calendar days from the date on the denial letter in which to submit a CAP.  CAPs may not be appealed further beyond the original review of the CAP.”

Source: NAHC Report

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