When billing privileges have been denied or revoked, the applicant/supplier has two options available to contest the determination. The applicant/supplier may submit a Corrective Action Plan (CAP) or submit a request for reconsideration When submitting your request, please keep in mind the following:
- The applicant/supplier must submit a CAP within 30 days from the postmark of the denial or revocation letter
- The request for reconsideration must be made within 60 days from the postmark of the denial or revocation letter
- The request must have the original signature of the authorized official, owner or partner on file
- The request must include an authorization letter signed by the authorized official that allows the NSC to communicate with an attorney if these services have been obtained
Note: According to Pub 100-8, Chapter 15, Section 25 a provider or supplier that is denied enrollment in the Medicare program or whose billing privileges have been revoked cannot submit a new enrollment application until the following has occurred:
- If the denial was not appealed, the provider or supplier may reapply after its appeal rights have lapsed
- If the denial was appealed, the provider or supplier may reapply after it has received notification the determination was upheld
- If the revocation is not overturned and all appeal optons are exhausted, the supplier must wait the enrollment bar as specified in the revocation letter
If you feel the NSC has made a factual mistake or the noncompliance issue has been corrected, the supplier may submit a CAP. The CAP is to ensure the business, at the location in question, is in compliance with the current supplier standards (42CFR424.57). Submission of a CAP shall contain, at a minimum, verifiable evidence of compliance and the sufficient assurance of the intent to comply fully with the supplier standards in the future.
The CAP and the acceptability of the plan is negotiated between the NSC/CMS and the applicant/supplier (42CFR422.57(d)). However, it is important to note that denials and revocations are generally based on noncompliance with the Supplier Standards. Being in compliance is non-negotiable.
If the NSC/CMS is satisfied the issues of noncompliance have been resolved, billing privileges may be issued or reinstated. If the applicant has been denied, the effective date of the billing privileges will be the day the NSC releases the number (1834 J of the Social Security Act and 42CFR422.57). If revoked, reinstatement will be effective the date CMS approves the CAP and the supplier has been determined to be in compliance with the supplier standards.
If the NSC/CMS upholds either a denial or a revocation, the applicant/supplier may request a reconsideration. Please note this request must be made within 60 days from the postmark of the letter issuing the initial determination, and not 60 days from the letter upholding the denial or revocation.
Reconsiderations (formerly Contractor Hearings)
A reconsideration request is specifically for an on-the-record hearing before a Hearing Officer (HO) not involved in the initial decision to deny or revoke billing privileges. Upon the receipt of a timely request, the NSC will forward the hearing package to the HO. The HO will then schedule, conduct and render a decision.
If you have any questions regarding this information, please contact the NSC Customer Line at (866) 238-9652.
DMEPOS suppliers choosing to appeal a Medicare denial or revocation are encouraged to use the Hearings and Appeals checklist when submitting documentation for review. Suppliers are still required to submit a detailed cover letter specifying the request of reconsideration or a CAP. The checklist should be submitted along with the CAP/reconsideration packet.
Please select the link below to access the Hearings and Appeals checklist.