What are the reasons why an application may be denied?


Answer:
Per 42 CFR §424.530(a) and Pub 100-08 - Medicare Program Integrity Manual, Chapter 10, Section 10.4.2.2, contractors can simply deny an enrollment application if any of the situations described below are present. If an application is denied, the supplier will receive a letter detailing why the application was denied and explaining the appeal options available.

Denial Reason 1 (42 CFR §424.530(a)(1)) – Not in Compliance with Medicare Requirements

The supplier is determined not to be in compliance with the enrollment requirements in subpart P (of Part 424) or in the enrollment application applicable to its supplier type and has not submitted a plan of corrective action as outlined in part 488 of this chapter. Such non-compliance includes, but is not limited to, the following situations:

  • The provider or supplier does not have a physical business address where services can be rendered. 
  • The provider or supplier does not have a place where patient records are stored to determine the amounts due such provider or other person. 
  • The provider or supplier is not appropriately licensed. 
  • The provider or supplier is not authorized by the federal/state/local government to perform the services it intends to render. 
  • The provider or supplier does not meet CMS regulatory requirements for the specialty it seeks to enroll. (See section 10.2.8 of this PIM chapter for examples of suppliers that are not eligible to participate.)
  • The provider or supplier does not have a valid social security number (SSN) or employer identification number (EIN) for itself, an owner, partner, managing organization/employee, officer, director, medical director, and/or authorized or delegated official.
  • The applicant does not qualify as a provider of services or a supplier of medical and health services.  (For instance, the applicant is not recognized by any federal statute as a Medicare provider or supplier (see section 10.2.8 of this PIM chapter)). An entity seeking Medicare payment must be able to receive reassigned benefits from physicians in accordance with the Medicare reassignment provisions in § 1842(b)(6) of the Act (42 U.S.C. 1395u(b)). 
  • The provider or supplier does not otherwise meet general enrollment requirements.

Denial Reason 2 (42 CFR §424.530(a)(2)) – Excluded/Debarred from Federal Program

The supplier, any owner, managing employee, authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier who is required to be reported on the CMS 855 is: 

  • Excluded from the Medicare, Medicaid or any other federal health care program, as defined in 42 CFR §1001.2, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the Social Security Act, or
  • Debarred, suspended or otherwise excluded from participating in any other federal procurement or non-procurement program or activity in accordance with section 2455 of the Federal Acquisition Streamlining Act.

Denial Reason 3 (42 CFR §424.530(a)(3)) – Felony Conviction

The supplier or any owner or managing employee of the supplier was, within the preceding 10 years, convicted (as that term is defined in 42 CFR § 1001.2) of a federal or state felony offense that CMS determines to be detrimental to the best interests of the Medicare program and its beneficiaries. Offenses include, but are not limited in scope and severity to:

  • Felony crimes against persons, such as murder, rape, assault and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions.
  • Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. 
  • Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct.
  • Any felonies outlined in section 1128 of the Social Security Act.  

While a reenrollment bar is established for revoked providers/suppliers, this does not preclude the contractor from denying reenrollment to a provider/supplier convicted of a felony within the preceding 10-year period or that otherwise does not meet all of the criteria necessary to enroll in Medicare.
 
Denial Reason 4 (42 CFR §424.530(a)(4)) – False or Misleading Information on Application

The provider or supplier submitted false or misleading information on the enrollment application to gain enrollment in the Medicare program.

Denial Reason 5 (42 CFR §424.530(a)(5)) – On-Site Review/Other Reliable Evidence that Requirements Not Met

CMS determines, upon onsite review or other reliable evidence, the supplier is not operational to furnish Medicare covered items or services, or does not meet Medicare enrollment requirements.
 
42 C.F.R. 424.502 defines operational as follows:
 
"Operational means the provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims, and is properly staffed, equipped and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered) to furnish these items or services." 

Denial Reason 18 (42 CFR §424.530(a)(18)) – Standard or Condition Violation

The supplier is non-compliant with any provision in 424.57(c)(11) - Beneficiary Solicitation, 424.57(c)(22) - Accrediation for products/services, 424.57(c)(24) - DMEPOS Accreditation Quality Standards or 424.57(c)(29) - Sharing space with other Medicare suppliers

 

For denial reasons 6 through 17, refer to the full list at: eCFR § 424.530 Denial of enrollment in the Medicare program. 


Last Updated: 03/25/2025