Corporate

February 12, 2018

Provider Enrollment Appeals Process

Overview

A provider or supplier whose Medicare enrollment is denied, or whose Medicare billing privileges have been revoked may file an appeal. A provider or supplier may also appeal their effective date. The revocation, denial, or approval letter will identify if a Corrective Action Plan (CAP) or Reconsideration is available.

Note: All CAPs and Reconsideration requests for Part B certified providers, Ambulatory Surgery Centers (ASCs) and Portable X-Ray Suppliers (PXRS) should be submitted directly to CMS.

Reconsideration Requests

A reconsideration disputes the MACs determination. A reconsideration review determines if the action taken by the MAC was correct at the time of action.

  • Reconsideration appeal rights are offered for initial effective date determinations, denied applications, and revocations. You may request a reconsideration if you have a letter from CGS that indicates you have reconsideration rights.
  • The reconsideration request must be filed within 60 days from the date on the initial determination letter. If the reconsideration request is filed after the 60 day timeframe, the reconsideration request will be returned.
  • Reconsideration requests should be mailed to the address indicated in the initial determination letter.
  • The reconsideration request should be in the form of a letter specifically requesting a reconsideration, and must be signed by the provider, authorized/delegated official, or a legal representative. A contact person is not considered a legal representative, and cannot sign the reconsideration request.
  • The reconsideration request should state the issues or findings of the fact with which you disagree, and the reasons for the disagreement. You may include any additional information, or documents to support the provider/supplier's case.
  • Once a reconsideration request is received, a CGS decision letter will be issued within 90 days. The decision letter will be sent via mail or e-mail.

Corrective Action Plan (CAP)

A CAP is an opportunity to correct deficiencies that resulted in the denial of an application, or a revocation of billing privileges.

  • A CAP must be submitted within 30 days from the date of the denial or revocation notice.
  • CAPs should be mailed to the address indicated in the initial determination letter.
  • CAPs should be in the form of a letter specifically requesting a CAP, and must be signed by the provider, authorized/delegated official, or a legal representative. A contact person is not considered a legal representative, and cannot sign the reconsideration request.
  • The CAP must provide evidence that the provider/supplier is in compliance with Medicare requirements. If applicable, include a corrected form CMS-855, and/or any other documentation.
  • Once a CAP is received, a CGS decision letter will be issued within 60 days. The letter will be sent via mail or e-mail.

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