Provider Enrollment Appeals and Rebuttal

Provider Enrollment Appeals Process

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Provider Enrollment Appeals Process

The provider enrollment appeals process applies to all provider/suppliers and offers appeal rights for initial determinations, for the following reasons:

  • Denial of enrollment in the Medicare Program
  • Revocation of a provider’s or supplier’s Medicare billing privileges
  • Effective date of participation in the Medicare Program

Upon receipt of the notification letter advising of the initial determination, a provider or supplier should review the appeals information included in the letter. There are two types of enrollment appeals; CAPs and reconsiderations, defined below in detail. If a provider or supplier wishes to appeal a denial, revocation, or effective date determination, the request must be submitted within 35 days of the date of the notice, if exercising CAP rights and within 65 days of the date of the notice, if exercising reconsideration rights. See CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10 (10.6.18), Appeal Process for additional information.

Utilize the Provider Enrollment Appeal Cover Sheet and include the denial letter with all documents to support request, as part of the submission. Provide identifying information to ensure proper identification in the letter including case number related to the appeal, provider or supplier’s legal name, NPI and PTAN. Ensure the letter is signed by the appropriate individual before submission.

Important: Authorized or delegated officials from a group cannot be an authorized representative of an individual provider to sign and submit a request on their behalf without written notice submitted with appeal.

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Corrective Action Plans

A CAP is a plan that allows a provider or supplier an opportunity to demonstrate compliance by correcting the deficiencies (if possible) that led to the initial determination. CAPs may only be submitted in response to enrollment denials pursuant to 42 CFR, Section 424.530(a)(1) and revocation of Medicare billing privileges pursuant to 42 CFR, Section 424.535(a)(1).

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Requirements for CAP Submission

  1. Must contain, at a minimum, verifiable evidence that the provider or supplier is in compliance with all applicable Medicare requirements.
  2. Must be received within 35 calendar days from the date of the initial determination. The contractor shall accept a CAP via hard-copy mail and email.
  3. Must be submitted in the form of a letter that is signed by the individual provider or supplier, the authorized or delegated official that has been reported within your Medicare enrollment record, or a properly appointed representative.
  4. Should include all documentation and information the provider or supplier would like to be considered in reviewing the CAP.
  5. For denials, the denial must be based on 42 CFR, Section 424.530(a)(1).
  6. For revocations, the revocation must be based on 42 CFR, Section 424.535(a)(1).

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Reconsiderations

A reconsideration request allows the provider or supplier an opportunity to demonstrate that an error was made in the initial determination at the time the initial determination was implemented. In contrast to a CAP, a reconsideration request does not allow a provider or supplier the opportunity to correct the deficiencies that led to the initial determination.

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Requirements for Reconsideration Request Submission

  1. Must contain, at a minimum, state the issues or the findings of fact with which the affected party disagrees and the reasons for disagreement.
  2. Must be received within 65 calendar days from the date of the initial determination. The contractor shall accept a reconsideration request via hard-copy mail and email.
  3. Must be submitted in the form of a letter that is signed by the individual provider or supplier, the authorized or delegated official that has been reported within your Medicare enrollment record, or a properly appointed representative.
  4. Should include all documentation and information the provider or supplier would like to be considered in reviewing the reconsideration request.

Note: If an appeal is found unfavorable, higher appeal rights may exist. See decision letter additional appeal rights.

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Revised 7/18/2024