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Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
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Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 1: Introduction
Voluntary and Involuntary Termination of Provider Agreement
Table of Contents
- Voluntary and Involuntary Termination of Provider Agreement
- Voluntary (Provider-Requested) Termination of Agreement
- Involuntary Termination (CMS Cancellation of Provider Agreement)
- Payment Exceptions
- Collecting Overpayments from Terminated Providers
- Related Content
Voluntary and Involuntary Termination of Provider Agreement
For various reasons, providers may find it necessary to voluntarily terminate their participation with the Medicare Program. In other circumstances, providers may have to be involuntarily removed from the Medicare Program.
The CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.6.1 regulation states a provider may voluntarily terminate its participation in the program or have participation involuntarily terminated by CMS.
Voluntary (Provider-Requested) Termination of Agreement
If a provider would like to terminate its agreement with Medicare, instructions can be found in the CMS IOM Publication, 100-01 Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.6.1.
The regulations state a provider may terminate its agreement to participate with Medicare by:
- Filing a written notice to CMS stating its intention to terminate, and
- Informing CMS of the official date the termination takes effect. CMS may take the date notated or set a different date. The termination date must be the first date of a month.
As soon as the termination date is established, CMS will instruct the provider to notify the public it is voluntarily terminating its provider agreement. The public notice should be published in the local paper with the largest circulation as soon as possible but not less than 15 days before the effective termination date. The provider should also file a CMS-855A to request a voluntary termination of its Medicare billing number.
Involuntary Termination (CMS Cancellation of Provider Agreement)
Medicare regulations also state CMS may terminate a provider’s Medicare agreement if it has determined the provider:
- Is not complying with Medicare guidelines and/or regulations
- No longer meets the appropriate requirements for participation
- Has failed to supply cost report information or
- Refuses to participate in audits of financial and/or medical records.
Whether the termination is voluntary or involuntary, CMS notifies the provider of the termination effective date via written correspondence. As of that date, no further payment will be made by the Medicare Program.
Payment Exceptions
Payment can continue to be made for up to 30 days for inpatient hospital services, swing-bed extended care services and/or SNF post-hospital extended care services furnished on or after the termination date to beneficiaries who were admitted prior to the termination date.
Payment may be made for services under a plan of treatment for up to 30 days following the effective termination date of a home health agency or hospice if the plan was established before the termination date.
Collecting Overpayments from Terminated Providers
If the contractor discovers an overpayment due from a terminated provider (defined as no longer participating with Medicare or Medicaid), the provider will be contacted with a request for a lump sum payment. Additional collections activities will follow, as appropriate.
However, if the provider is no longer with Medicare but still participating in the Medicaid program, action to withhold a Federal share of Medicaid payments can be initiated, as appropriate.
Related Content
- CMS IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5 – Definitions, Section 10
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements, Section 40
- CMS-IOM Publication 100-06, Medicare Financial Management Manual, Chapter 3 – Overpayments, Section 20
Reviewed 6/4/2024