CMS Extends Appeal Rights When Applications for Medicare Billing Privileges Are Denied or Revoked

July 3, 2008


The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that extends appeal rights to all providers and suppliers—including durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) suppliers—whose enrollment applications for Medicare billing privileges are denied or revoked by CMS or a Medicare contractor. Entitled “Medicare Program; Appeals of CMS or CMS Contractor Determinations When a Provider or Supplier Fails to Meet the Requirements for Medicare Billing Privileges,” the rule will also allow providers and suppliers to seek judicial review after they have exhausted the administrative appeals process.

The final rule states: if a carrier or Medicare Appeals Council (MAC) denies a provider’s or supplier’s enrollment application or revokes a provider’s or supplier’s Medicare billing privileges, then the carrier or MAC must notify the provider or supplier by mail. The notice must include the following: (1) The reason for denial in sufficient detail to allow the provider or supplier to understand the nature of its deficiencies; (2) the right to appeal in accordance with part 498; and (3) the address to which the written appeal must be mailed.

The CMS rule also establishes a number of provisions, including

  • An enrollment bar for those providers and suppliers whose billing privileges are revoked
  • A new revocation reason for services that could not have been provided
  • A requirement that providers and suppliers receive payments by electronic funds transfer (EFT) when enrolling, making a change to their enrollment information, or during a revalidation process
  • A change in the timeframe from 60 days to 30 days for when Medicare contractors can reject an enrollment application if a provider or supplier fails to provide missing information/documentation
  • Timeframes for processing initial enrollment application, changes, and appeals

The final rule goes into effect on August 26, 2008. Access the final rule in its entirety.