CMS Pub. 100-08, ch. 10, § 10.4.7.2

A. Effective Dates

The contractor shall apply a revocation effective date based upon federal regulations at §

424.535(g). In general, and as discussed below, these dates are either prospective or retroactive.

1. Revocations with Retroactive Effective Dates (§ 424.535(g)(2))

These revocation grounds require the following retroactive effective dates per § 424.535(g)(2):

(i) Federal exclusion or debarment – Date of exclusion/debarment

(ii) Felony conviction – Date of felony conviction

(iii) License suspension or revocation – Date of license suspension or revocation

(iv) Determination that the provider or supplier is no longer operational – Date provider/supplier

no longer operational

(v) State license surrender in lieu of further disciplinary action – Date of license surrender

(vi) Termination from a federal health care program other than Medicare (for example,

Medicaid) – Date of termination

(vii) Termination of a provider agreement under 42 CFR Part 489 – Later of date of provider

agreement termination or date CMS establishes under § 489.55

(viii) Lapse in IDTF’s comprehensive liability insurance policy under § 410.33(g)(6) – Date

insurance lapsed

(ix) Submission of false or misleading information on the enrollment application - Date the

application's certification statement was signed

(x) Failure to timely report a change of ownership or adverse legal action, or a change,

addition, or deletion of a practice location – Day after the date by which the provider or supplier

was required to report the change, addition, or deletion

(xi) Surrender of Drug Enforcement Administration certificate of registration in response to a

show cause order - Date the certificate was surrendered

(xii) State suspension or revocation of the physician's/practitioner's ability to prescribe one or

more drugs - Date of the suspension or revocation

(xiii) Revocation of any of the provider's or supplier's other enrollments under § 424.535(i) - The

effective date of the revocation that triggered the revocation(s) of the other enrollment(s)

(xiv) DMEPOS supplier's non-compliance with a condition or standard in § 424.57(b) or (c) –

Date on which the non-compliance began

(xv) Violation of provider or supplier standard as described in 42 CFR §§ 424.535(a)(23) -

• If the standard or condition violation involves the suspension, revocation, or

termination (or surrender in lieu of further disciplinary action) of the provider's or supplier's

federal or state license, certification, accreditation, or MDPP recognition, the effective date is

the date of the license, certification, accreditation, or MDPP recognition suspension, revocation,

termination, or surrender.

• If the standard or condition violation involves a non-operational practice location, the

effective date is the date the non-operational status began.

• If the standard violation involves a felony conviction of an individual or entity described

in § 424.67(b)(6)(i), the effective date is the date of the felony conviction.

(For all standard violations not addressed in § 424.535(g)(2) above, the effective date in §

424.535(g)(1) (see below) applies if the effective date in § 424.535(g)(3) does not.)

In addition, and as stated in § 424.535(a)(8)(iii), the following effective dates apply to

revocations under § 424.535(a)(8):

• § 424.535(a)(8)(i) – The earliest date of service on the claim or claims that is or are

triggering the revocation

• § 424.535(a)(8)(ii) – The last date of service on the claims in question

2. Revocations with Prospective Effective Dates (§ 424.535(g)(1))

The contractor shall use a prospective effective date (i.e., the date that is 30 days after CMS or

the CMS contractor mails notice of its determination to the provider) for revocations not based

upon one of the reasons listed in §§ 424.535(g)(2) and section 10.4.7.2(A)(1) above (e.g., §

424.535(a)(8) -- abuse of billing).

3. Pre-Enrollment Actions (§ 424.535(g)(3))

If the action that triggered the revocation occurred before the provider’s or supplier’s enrollment,

the revocation effective date is the enrollment effective date that CMS assigned to the provider

or supplier. To illustrate, for a revocation involving an adverse legal action that occurred on

February 1 (of which CMS was not aware) and the provider was enrolled effective April 1, the

revocation effective date would be April 1 rather than February 1. Strictly for purposes of

applying § 424.535(g)(3) -- and notwithstanding any guidance to the contrary in section 10.6.2 of

this chapter – the effective date of enrollment is the date that was established under §§ 424.520

or 424.521, whichever is earlier.

B. Revocations Based Upon More than One Reason

When a revocation involves more than one reason, the contractor shall determine whether any of

the grounds require a retroactive effective date (as described above in section 10.4.7.2(A) above;

if a retroactive date is indeed implicated, the contractor shall apply the appropriate retroactive

date.