CMS Pub. 100-08, ch. 10, § 10.4.7.3

Sections 10.4.7.3(A) through (V) list the revocation reasons in 42 CFR § 424.535. Section

10.4.7.3(W) discusses extensions of revocations per 42 CFR § 424.535(i).

A. Revocation Reason 1 – Noncompliance (42 CFR § 424.535(a)(1))

“The provider or supplier is determined not to be in compliance with the enrollment

requirements in this Title 42 or in the enrollment application applicable to its provider or supplier

type and has not submitted a plan of corrective action as outlined in 42 CFR Part 488. The

provider or supplier may also be determined not to be in compliance if it has failed to pay any

user fees as assessed under part 488 of this chapter.”

(Title 42 includes the principal provider enrollment regulations in 42 CFR Part 424, subpart P;

the IDTF enrollment standards in 42 CFR § 410.33; the OTP enrollment standards in 42 CFR §

424.67; etc.)

Noncompliance includes but is not limited to: (1) the provider/supplier no longer has a physical

business address or mobile unit where services can be rendered; (2) the provider/supplier does

not have a place where patient records are stored to determine the amounts due such provider or

other person; and/or (3) the provider/supplier no longer meets or maintains general enrollment

requirements. Noncompliance also includes situations when the provider/supplier has failed to

pay any user fees as assessed under 42 CFR Part 488.

Other situations (some of which were mentioned in the previous paragraph) in which §

424.535(a)(1) may be used as a revocation reason include, but are not limited to, the following:

• The provider or supplier does not have a physical business address or mobile unit 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. (NOTE: For (a)(1) revocations

involving an individual practitioner who is not appropriately licensed due to a disciplinary

action, PEOG -- rather than the contractor -- will make all determinations to revoke for this

noncompliance requirement).

• The provider or supplier is not authorized by the federal/state/local government to

perform the services that it intends to render.

• The provider or supplier does not meet CMS regulatory requirements for the specialty

that it is enrolled as.

• 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 provider or supplier fails to furnish complete and accurate information and all

supporting documentation within 60 calendar days of the provider/supplier’s notification from

CMS or its contractor to submit an enrollment application and supporting documentation, or

resubmit and certify to the accuracy of its enrollment information. (This revocation reason will

not apply if CMS has instructed the contractor to use deactivation reason § 424.540(a)(3) in lieu

thereof.)

• The provider or supplier does not otherwise meet general enrollment requirements.

(Concerning the last bullet above – and, as applicable, bullets 3, 4 and 5 – the contractor’s

revocation letter shall cite the appropriate statutory and/or regulatory citation(s) containing the

specific licensure/certification/authorization requirement(s) for that provider/supplier type.)

Special Instructions Regarding Certified Providers/Suppliers – The SOG Location may

involuntarily terminate a certified provider/supplier if the latter no longer meets CMS

requirements, conditions of participation, or conditions of coverage. When this occurs, CMS

terminates the provider'/supplier’s provider agreement and notifies the contractor thereof. Upon

receipt of the CMS notice (and except as otherwise stated in this chapter), the contractor shall

follow the revocation procedures in this chapter (including, as applicable, those in section

10.6.6)), using § 424.535(a)(1) as the revocation basis; the contractor shall not process the

involuntary termination as a deactivation based upon a voluntary withdrawal from Medicare.

Note that the contractor need not (but certainly may) contact the SOG Location to obtain further

details of the termination.

B. Revocation Reason 2 – Provider or Supplier Conduct (42 CFR § 424.535(a)(2))

“(i) The provider or supplier, or any owner, managing employee, managing organization, officer,

director, authorized or delegated official, medical director, supervising physician, or other health

care or administrative or management personnel furnishing services payable by a federal health

care program, of the provider or supplier is:

(A) Excluded from the Medicare, Medicaid, and 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 Act.

(B) Is debarred, suspended, or otherwise excluded from participating in any other federal

procurement or non-procurement program or activity in accordance with the FASA

implementing regulations and the Department of Health and Human Services non-procurement

common rule at 45 CFR part 76.

(ii) The individuals and organizations identified in paragraph (a)(2)(i) of this section include, but

are not limited to, W–2 employees and contracted individuals and organizations of the provider

or supplier.”

If the contractor finds an excluded party (and unless section 10.6.6 states otherwise, in which

case the latter section takes precedence), the contractor shall notify its PEOG BFL immediately.

PEOG will notify the Contracting Officer’s Representative (COR) for the appropriate Unified

Program Integrity Contractor (UPIC). The COR will, in turn, contact the OIG for further

investigation.

C. Revocation Reason 3 – Felony Conviction (42 CFR § 424.535(a)(3))

“The provider, supplier, or any owner, managing employee, managing organization, officer, or

director of the provider or 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. [Under §

424.535(a)(3)(ii),] [o]ffenses 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 that would result in mandatory exclusion under section 1128(a) of the Act.

[Under § 424.535(a)(3)(iii),] revocations based on felony convictions are for a period to be

determined by the Secretary, but not less than 10 years from the date of conviction if the

individual has been convicted on one previous occasion for one or more offenses.”]

[Under § 424.535(a)(3)(iv),] the individuals and organizations identified in paragraph (a)(3) of

this section include, but are not limited to, W–2 employees and contracted individuals and

organizations of the provider or supplier.]

The expiration of a reenrollment bar issued pursuant to 42 CFR § 424.535(c) does not preclude

CMS or its contractors from denying reenrollment to a provider that (i) was convicted of a felony

within the preceding 10-year period or (ii) otherwise does not meet all criteria necessary to enroll

in Medicare.

D. Revocation Reason 4 – False or Misleading Information on Application (42 CFR §

424.535(a)(4))

“The provider or supplier certified as ‘‘true’’ misleading or false information on the enrollment

application to be enrolled or maintain enrollment in the Medicare program. (Offenders may be

subject to either fines or imprisonment, or both, in accordance with current laws and

regulations.)”

E. Revocation Reason 5 - On-Site Review/Other Reliable Evidence that Requirements Not

Met (42 CFR § 424.535(a)(5))

“Upon onsite review or other reliable evidence, CMS determines that the provider or supplier:

(i) Is not operational to furnish Medicarecovered items or services; or

(ii) Otherwise fails to satisfy any Medicare enrollment requirement.”

F. Revocation Reason 6 - Hardship Exception Denial and Fee Not Paid (42 CFR

§424.535(a)(6))

(i) An institutional provider does not submit an application fee or hardship exception request

that meets the requirements set forth in § 424.514 with the Medicare revalidation application; or

(ii) The hardship exception is not granted and the institutional provider does not submit the

applicable application form or application fee within 30 days of being notified that the hardship

exception request was denied.

(iii) Either of the following occurs:

• CMS is not able to deposit the full application amount into a government-owned account;

or

• The funds are not able to be credited to the United States Treasury;

(iv) The provider or supplier lacks sufficient funds in the account at the banking institution

whose name is imprinted on the check or other banking instrument to pay the application fee; or

(v) There is any other reason why CMS or its Medicare contractor is unable to deposit the

application fee into a government-owned account.

G. Revocation Reason 7 – Misuse of Billing Number (42 CFR § 424.535(a)(7))

“The provider or supplier knowingly sells to or allows another individual or entity to use its

billing number. This does not include those providers or suppliers that enter into a valid

reassignment of benefits as specified in 42 CFR § 424.80 or a change of ownership as outlined in

42 CFR § 489.18.”

H. Revocation Reason 8 – Abuse of Billing Privileges (42 CFR § 424.535(a)(8))

“Abuse of billing privileges includes either of the following:

(i) The provider or supplier submits a claim or claims for services that could not have been

furnished to a specific individual on the date of service. These instances include but are not

limited to the following situations:

(A) Where the beneficiary is deceased.

(B) The directing physician or beneficiary is not in the state or country when services were

furnished.

(C) When the equipment necessary for testing is not present where the testing is said to have

occurred.

(D) The beneficiary attests that the item(s) or service(s) identified on the provider’s or supplier’s

claim or claims was not or were not rendered or furnished.

(ii) CMS determines that the provider or supplier has a pattern or practice of submitting claims

that fail to meet Medicare requirements. In making this determination, CMS considers, as

appropriate or applicable, the following factors:

(A) The percentage of submitted claims that were denied during the period under consideration.

(B) Whether the provider or supplier has any history of final adverse actions (as that term is

defined in § 424.502) and the nature of any such actions.

(C) The type of billing non-compliance and the specific facts surrounding said non-compliance

(to the extent this can be determined).

(D) Any other information regarding the provider or supplier's specific circumstances that CMS

deems relevant to its determination.”

(NOTE: Concerning (a)(8), PEOG -- rather than the contractor -- will (1) make all

determinations regarding whether a provider has a pattern or practice of submitting non-compliant claims; (2) consider the relevant factors; and (3) accumulate all information needed to

make such determinations.)

I. Revocation Reason 9 – Failure to Report (42 CFR § 424.535(a)(9))

“The provider or supplier failed to comply with the reporting requirements specified in 42 CFR §

424.516(d) or (e), § 410.33(g)(2), or § 424.57(c)(2) [which pertain to the reporting of changes in

adverse actions and practice locations].”

With respect to § 424.535(a)(9) (and except as otherwise stated in section 10.6.6):

• If the provider reports a change in practice location more than 30 days after the effective

date of the change, the contractor shall not pursue a revocation on this basis. However, if the

contractor independently determines – through an on-site inspection under 42 CFR §

424.535(a)(5)(ii) or via another verification process - that the provider’s address has changed but

the provider has not notified the contractor thereof within the aforementioned 30-day timeframe,

the contractor may pursue a revocation (e.g., seeking PEOG’s approval to revoke).

• If an IDTF reports a change in ownership, change of location, change in general

supervision or change in adverse legal action more than 30 days after the effective date of the

change, the contractor may pursue a revocation on this basis (e.g., seeking PEOG’s approval to

revoke).

• If a DMEPOS supplier reports a change of information more than 30 days after the

effective date of the change, the contractor may pursue a revocation on this basis (e.g., seeking

PEOG’s approval to revoke).

J. Revocation Reason 10 – Failure to Document or Provide CMS Access to Documentation

(42 CFR § 424.535(a)(10))

“The provider or supplier did not comply with the documentation requirements specified in 42

CFR § 424.516(f). A provider that furnishes any covered ordered, certified, referred, or

prescribed Part A or B services, items or drugs is required to maintain documentation for 7

years.”

K. Revocation Reason 11 - Home Health Agency (HHA) Capitalization (42 CFR §

424.535(a)(11))

“An HHA fails to furnish - within 30 days of a CMS or contractor request - supporting

documentation verifying that the HHA meets the initial reserve operating funds requirement

found in 42 CFR § 489.28(a).”

L. Revocation Reason 12 – Other Program Termination (42 CFR § 424.535(a)(12))

“The provider or supplier is terminated, revoked, or otherwise barred from participation in a

particular State Medicaid Agency or any other federal health care program.”

In making its determination, CMS considers the following factors listed in 42 CFR §

424.535(a)(12):

“(A) The reason(s) for the termination or revocation;

(B) Whether the provider or supplier is currently terminated, revoked, or otherwise barred from

more than one program (for example, more than one state's Medicaid program) or has been

subject to any other sanctions during its participation in other programs; and;

(C) Any other information that CMS deems relevant to its determination.”

Under § 424.535(a)(12)(ii), “Medicare may not revoke [a provider/supplier’s Medicare billing

privileges] unless and until the provider or supplier has exhausted all applicable appeal rights or

the timeframe for filing an appeal has expired without the provider or supplier filing an appeal.”

M. Revocation Reason 13 - Prescribing Authority (42 CFR § 424.535(a)(13))

“(i) The physician or eligible professional's Drug Enforcement Administration (DEA) Certificate

of Registration is suspended or revoked or is surrendered in response to an order to show cause;

or

(ii) The applicable licensing or administrative body for any state in which the physician or

eligible professional practices suspends or revokes the physician’s or other eligible professional's

ability to prescribe one or more drugs.”

N. Revocation Reason 14 – Improper Prescribing Practices (42 CFR § 424.535(a)(14))

“CMS determines that the physician or other eligible professional has a pattern or practice of

prescribing Medicare-covered drugs that falls into one of the following categories:

(i) The pattern or practice is abusive or represents a threat to the health and safety of

Medicare beneficiaries or both. In making this determination, CMS considers the following

factors:

(A) Whether there are diagnoses to support the indications for which the drugs were prescribed;

(B) Whether there are instances when the necessary evaluation of the patient for whom the drug

was prescribed could not have occurred (for example, the patient was deceased or out of state at

the time of the alleged office visit);

(C) Whether the physician or eligible professional has prescribed controlled substances in

excessive dosages that are linked to patient overdoses;

(D) The number and type(s) of disciplinary actions taken against the physician or eligible

professional by the licensing body or medical board for the State or States in which the

individual practices, and the reason(s) for the action(s);

(E) Whether the physician or eligible professional has any history of final adverse actions (as

that term is defined in § 424.502);

(F) The number and type(s) of malpractice suits that have been filed against the physician or

eligible professional related to prescribing that have resulted in a final judgment against the

physician or eligible professional or in which the physician or eligible professional has paid a

settlement to the plaintiff(s) (to the extent this can be determined);

(G) Whether any State Medicaid program or any other public or private health insurance

program has restricted, suspended, revoked, or terminated the physician or eligible professional's

ability to prescribe medications, and the reason(s) for any such restriction, suspension,

revocation, or termination; and

(H) Any other relevant information provided to CMS.

(ii) The pattern or practice of prescribing fails to meet Medicare requirements. In making

this determination, CMS considers the following factors:

(A) Whether the physician or eligible professional has a pattern or practice of prescribing

without valid prescribing authority.

(B) Whether the physician or eligible professional has a pattern or practice of prescribing for

controlled substances outside the scope of the prescriber's DEA registration.

(C) Whether the physician or eligible professional has a pattern or practice of prescribing drugs

for indications that were not medically accepted - that is, for indications neither approved by the

FDA nor medically accepted under section 1860D-2(e)(4) of the Act - and whether there is

evidence that the physician or eligible professional acted in reckless disregard for the health and

safety of the patient.”

(NOTE: Concerning (a)(14), PEOG -- rather than the contractor -- will (1) make all

determinations regarding whether a provider/supplier has a pattern or practice of prescribing Part

B or D drugs; (2) consider the relevant factors; and (3) accumulate all information needed to

make such determinations.)

O. Revocation Reason 15 – False Claims Act Judgment (42 CFR § 424.535(a)(15))

“(i) The provider or supplier, or any owner, managing employee or organization, officer, or

director of the provider or supplier, has had a civil judgment under the False Claims Act (31

U.S.C. 3729 through 3733) imposed against them within the previous 10 years.

(ii) In determining whether a revocation under this paragraph is appropriate, CMS considers the

following factors:

(A) The number of provider or supplier actions that the judgment incorporates (for example, the

number of false claims submitted)

(B) The types of provider or supplier actions involved

(C) The monetary amount of the judgment

(D) When the judgment occurred

(E) Whether the provider or supplier has any history of final adverse actions (as that term is

defined in § 424.502)

(F) Any other information that CMS deems relevant to its determination.”

NOTE: With respect to (a)(15), PEOG -- rather than the contractor – will make all

determinations regarding whether this provision applies.

P. Revocation Reason 17 – Debt Referred to the United States Department of Treasury (42

CFR § 424.535(a)(17))

“The provider or supplier has failed to repay a debt that CMS appropriately refers to the United

States Department of Treasury.” In determining whether a revocation is appropriate, CMS

considers the following factors:

“(i)(A) The reason(s) for the failure to fully repay the debt (to the extent this can be determined);

(B) Whether the provider or supplier has attempted to repay the debt (to the extent this can be

determined);

(C) Whether the provider or supplier has responded to CMS' requests for payment (to the extent

this can be determined);

(D) Whether the provider or supplier has any history of final adverse actions or Medicare or

Medicaid payment suspensions;

(E) The amount of the debt; and

(F) Any other evidence that CMS deems relevant to its determination.”

(NOTE: With respect to (a)(17):

• Section 424.535(a)(17)(ii) excludes from paragraph (a)(17)(i)’s purview those cases

where: (1) the provider’s or supplier’s Medicare debt has been discharged by a bankruptcy court;

or (2) the administrative appeals process concerning the debt has not been exhausted or the

timeline for filing such an appeal, at the appropriate appeal level, has not expired.

• PEOG – rather than the contractor – will make all (a)(17) determinations.

Q. Revocation Reason 18 – Revoked Under a Different Name, Numerical Identifier or

Business Identity (42 CFR § 424.535(a)(18))

“The provider or supplier is currently revoked [from Medicare] under a different name,

numerical identifier, or business identity, and the applicable reenrollment bar period has not

expired.” In making its determination, CMS considers the following factors:

“(i) Owning and managing employees and organizations (regardless of whether they have been

disclosed on the Form CMS-855 [or CMS-20134] application);

(ii) Geographic location;

(iii) Provider or supplier type;

(iv) Business structure; or

(v) Any evidence indicating that the two parties [the revoked provider or supplier and newly

enrolling provider or supplier] are similar or that the provider or supplier was created to

circumvent the revocation or reenrollment bar.”

(NOTE: Concerning (a)(18), PEOG – rather than the contractor – will make all determinations

regarding whether a provider/supplier was revoked under a different name, numerical identifier,

or business identity.)

R. Revocation Reason 19 – Affiliation that Poses an Undue Risk (42 CFR § 424.535(a)(19))

1. Specific Reason

“The provider or supplier has or has had an affiliation under 42 CFR § 424.519 that poses an

undue risk of fraud, waste and abuse to the Medicare program.” In making this determination,

CMS considers the following factors listed in 42 CFR § 424.519(f)(1) through (6):

“(1) The duration of the affiliation

(2) Whether the affiliation still exists and, if not, how long ago it ended

(3) The degree and extent of the affiliation

(4) If applicable, the reason for the termination of the affiliation

(5) Regarding the affiliated provider/supplier's disclosable event [under § 424.519(b)]:

(i) The type of disclosable event.

(ii) When the disclosable event occurred or was imposed.

(iii) Whether the affiliation existed when the disclosable event occurred or was imposed.

(iv) If the disclosable event is an uncollected debt: (A) the amount of the debt; (B) whether the

affiliated provider or supplier is repaying the debt; and (C) to whom the debt is owed.

(v) If a denial, revocation, termination, exclusion, or payment suspension is involved, the reason

for the disclosable event.

(6) Any other evidence that CMS deems relevant to its determination.”

2. Definition of Affiliation

For purposes of § 424.519 only, 42 CFR § 424.502 defines “affiliation” as:

• A 5 percent or greater direct or indirect ownership interest that an individual or entity has

in another organization.

• A general or limited partnership interest (regardless of the percentage) that an individual

or entity has in another organization.

• An interest in which an individual or entity exercises operational or managerial control

over, or directly or indirectly conducts, the day-to-day operations of another organization

(including, for purposes of [§ 424.519 only], sole proprietorships), either under contract or

through some other arrangement, regardless of whether or not the managing individual or entity

is a W–2 employee of the organization.

• An interest in which an individual is acting as an officer or director of a corporation.

• Any reassignment relationship under § 424.80.”

(NOTE: Concerning (a)(19), PEOG -- rather than the contractor -- will make all determinations

regarding whether a provider/supplier has an affiliation per § 424.519 that poses an undue risk of

fraud, waste, and abuse.)

S. Revocation Reason 20 – Billing from a Non-Compliant Location (42 CFR §

424.535(a)(20))

“CMS may revoke a provider's or supplier's Medicare enrollment or enrollments, even if all the

practice locations associated with a particular enrollment comply with Medicare enrollment

requirements, if the provider or supplier billed for services performed at or items furnished from

a location that it knew or should have known did not comply with Medicare enrollment

requirements. In determining whether and how many of the provider/supplier's enrollments

(involving the non-compliant location or other locations) should be revoked, CMS considers the

following factors [enumerated in § 424.535(a)(20)(i) through (vii)]:

• The reason(s) for and the specific facts behind the location’s non-compliance;

• The number of additional locations involved;

• The provider or suppliers possibly history of final adverse actions or Medicare or

Medicaid payment suspensions;

• The degree of risk the location’s continuance poses to the Medicare Trust Funds;

• The length of time that the location was considered non-compliant;

• The amount that was billed for services performed at or items furnished from the non-compliant location; and,

• Any other evidence that CMS deems relevant to its determination.”

(NOTE: Concerning (a)(20), PEOG – rather than the contractor – will make all determinations

regarding whether a provider/supplier has performed services or furnished items from a location

that did not comply with Medicare enrollment requirements.)

T. Revocation Reason 21 – Abusive Ordering, Certifying, Referring, or Prescribing of Part

A or B Services, Items or Drugs (42 CFR § 424.535(a)(21))

“The physician or eligible professional has a pattern or practice of ordering, certifying, referring

or prescribing Medicare Part A or B services, items or drugs that is abusive, represents a threat to

the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare

requirements.” In making its determination, CMS considers the following factors [enumerated in

§ 424.535(i) through (ix)]:

• Whether the physician or eligible professional’s diagnosis supports the order,

certification,

referral or prescription in question;

• Whether there are instances where the necessary evaluation of the patient for whom the

order, certification, referral or prescription could have not occurred (for example: the patient was

deceased or out of state at the time of the alleged office visit);

• The number and types of disciplinary actions taken against the physician or eligible

professional by the licensing body or medical board for the state(s) in which the individual

practices and the reason(s) for the action(s);

• Whether the physician or eligible professional has any history of final adverse actions (as

defined by 42 CFR § 424.502);

• The length of time over which the pattern or practice has continued;

• How long the physician or eligible professional has been enrolled in Medicare;

• The number of type(s) of malpractice suits that have been filed against the physician or

eligible professional related to ordering, certifying, referring or prescribing that resulted in a final

judgement against the physician or eligible professional or the physician or eligible professional

paid a settlement to the plaintiff(s) (to the extent this can be determined);

• Whether any State Medicaid Agency (SMA) or other public health insurance program has

restricted, suspended, revoked or terminated the physician’s or eligible professional’s ability to

practice medicine and reason for any such restriction, suspension, revocation or termination; and

• Any other information that CMS deems relevant to its determination.

(NOTE: Concerning (a)(21), PEOG – rather than the contractor – will make all determinations

regarding whether a physician or eligible professional has a pattern or practice of ordering,

certifying, referring or prescribing Medicare Part A or B services, items, or drugs that is abusive,

threatening to the safety of Medicare beneficiaries, or fails to meet Medicare requirements).

U. Revocation Reason 22 – Patient Harm (42 CFR § 424.535(a)(22))

The physician or other eligible professional has been subject to prior action from a state

oversight board, federal or state health care program, Independent Review Organization (IRO)

determination(s), or any other equivalent governmental body or program that oversees, regulates,

or administers the provision of health care with underlying facts reflecting improper physician or

other eligible professional conduct that led to patient harm. In determining whether a revocation

is appropriate, CMS considers the following factors [enumerated in § 424.535(a)(22)(i)(A)

through (E)):

A. The nature of the patient harm.

B. The nature of the physician's or other eligible professional's conduct.

C. The number and type(s) of sanctions or disciplinary actions that have been imposed

against the physician or other eligible professional by the state oversight board, IRO, federal or

state health care program, or any other equivalent governmental body or program that oversees,

regulates, or administers the provision of health care. Such actions include, but are not limited to

in scope or degree:

(i) License restriction(s) pertaining to certain procedures or practices.

(ii) Required compliance appearances before State medical board members.

(iii) License restriction(s) regarding the ability to treat certain types of patients.

(iv) Administrative or monetary penalties.

(v) Formal reprimand(s).

(D) If applicable, the nature of the IRO determination(s).

(E) The number of patients impacted by the physician/other eligible professional's conduct and

the degree of harm thereto or impact upon.”

(Per 42 CFR § 424.535(a)(22)(ii), paragraph (a)(22) does not apply to actions or orders

pertaining exclusively to either of the following:

• Required participation in rehabilitation or mental/behavioral health programs; or

• Required abstinence from drugs or alcohol and random drug testing.)

V. Revocation Reason 23 – Standard or Condition Violation (42 CFR § 424.535(a)(23))

(i) The independent diagnostic testing facility is non-compliant with any provision in 42 CFR

410.33(g).

(ii) The DMEPOS supplier is non-compliant with any provision in § 424.57(c).

(iii) The opioid treatment program is non-compliant with any provision in § 424.67(b) or (e).

(iv) The home infusion therapy supplier is non-compliant with any provision in § 424.68(c) or

(e).

(v) The Medicare diabetes prevention program is non-compliant with any provision in §

424.205(b) or (c).

(All revocations based wholly, or in part, on § 424.535(a)(23) shall be sent to PEOG to obtain

approval of both the revocation action itself and the revocation letter.) The contractor’s

revocation letter shall cite the exact statutory and/or regulatory citation(s) containing the specific

standard/condition with which the provider/supplier is non-compliant. For a listing of some of

these statutes and regulations, refer to section 10.2 et seq. of this chapter.)

(See section 10.4.7.5(A) for more information regarding § 424.535(a)(23).)

W. Extension of Revocation

If a provider’s Medicare enrollment is revoked under § 424.535(a), CMS may revoke any and all

of the provider’s Medicare enrollments, including those under different names, numerical

identifiers or business identities and those under different types. In determining whether to

revoke a provider’s other enrollments, CMS considers the following factors:

(i) The reason for the revocation and the facts of the case;

(ii) Whether any final adverse actions have been imposed against the provider or supplier

regarding its other enrollments;

(iii) The number and type(s) of other enrollments; and

(iv) Any other information that CMS deems relevant to its determination.