What is a CAP: |
The CAP is an opportunity for the provider/supplier to correct the deficiencies (if possible) that resulted in the denial or revocation of billing privileges. A CAP may only be submitted for denials under 42 C.F.R. § 424.530(a)(1) or revocation of billing privileges under 42 C.F.R. § 424.535(a)(1). |
What must be included with CAP: |
When submitting a CAP, it must:
- Contain verifiable evidence that the provider/supplier is in compliance with Medicare requirements;
- Be submitted within 35 days from the date of the denial or revocation notice;
- Be submitted in the form of a letter that is signed and dated by the individual provider/supplier, the authorized or delegated official, or a legal representative.
- If a legal representative is an attorney, the CAP must also contain a statement that the attorney has the authority to act on behalf of the provider/supplier. If the legal representative is not an attorney, the CAP must contain written notice of the appointment of the non-attorney as legal representative signed by the provider, supplier, or authorized/delegated official.
- CAP / Reconsideration form available here.
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MAC process of CAP: |
A decision will be issued within 60 days of receipt of the CAP. |
What is a Reconsideration: |
A reconsideration request is an opportunity for a provider/supplier to furnish evidence that demonstrates that there was an error made at the time of the initial determination affecting participation in the Medicare Program. |
What must be included with Reconsideration: |
When submitting a reconsideration request, it must:
- State the issues, or the findings of fact with which you disagree, and the reasons for disagreement.
- Be submitted within 65 days from the date of the initial determination;
- Be submitted in the form of a letter that is signed and dated by the individual provider/supplier, the authorized or delegated official, or a legal representative.
- If a legal representative is an attorney, the reconsideration request must also contain a statement that the attorney has the authority to act on behalf of the provider/supplier. If the legal representative is not an attorney, the reconsideration request must contain written notice of the appointment of the non-attorney as legal representative signed by the provider, supplier, or authorized/delegated official.
- CAP / Reconsideration form available here.
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MAC process of Reconsideration: |
A decision will be issued within 90 days of receipt of the reconsideration request. |
CAP or Reconsideration request should be sent to one of the following: |
Mail: |
Centers for Medicare & Medicaid Services
Center for Program Integrity
Provider Enrollment & Oversight Group
ATTN: Division of Provider Enrollment Appeals
7500 Security Blvd.
Mailstop: AR-19-51
Baltimore, MD 21244-1850
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or |
E-mail: |
ProviderEnrollmentAppeals@cms.hhs.gov |
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