CMS Pub. 100-08, ch. 10, § 10.4.7.4

If any inconsistency exists between an instruction in this section 10.4.7.4 and a directive in

section 10.6.6, the latter instruction takes precedence. In addition, the contractor shall adhere to

any instruction in section 10.6.6 that addresses a reenrollment bar matter not discussed in section

10.4.7.4.

A. Background

As stated in 42 CFR § 424.535(c), if a provider/supplier has billing privileges revoked, the

provider/supplier is barred from participating in the Medicare program from the effective date of

the revocation until the end of the reenrollment bar. The reenrollment bar begins 30 days after

CMS or its contractor mails notice of the revocation and lasts a minimum of 1 year, but not

greater than 10 years, depending on the severity of the basis for revocation. In addition, CMS

may impose a reenrollment bar of up to 20 years if the provider/supplier is being revoked from

Medicare for the second time.

Per § 424.535(c), the reenrollment bar does not apply if the revocation: (i) is based on §

424.535(a)(1); and (ii) stems from a provider/supplier’s failure to respond timely to a

revalidation request or other request for information. If both of these conditions are met, no

reenrollment bar will be applied.

The contractor shall update PECOS to reflect that the individual cannot participate in Medicare

for the applicable length of the reenrollment bar. Except as otherwise stated in this chapter,

PEOG (rather than the contractor) determines reenrollment bars that exceed 3 years.

In addition, CMS may add up to 3 more years to the provider/supplier's reenrollment bar if it

determines that the provider/supplier is attempting to circumvent its existing reenrollment bar.

B. Establishment of Length

The following serves merely as general, non-binding guidance regarding the establishment of the

length of reenrollment bars. It is crucial to note that every situation must and will be judged on

its own merits, facts, and circumstances. It should not be assumed that a particular timeframe

will always be applied to a specific revocation reason in all cases. CMS retains the discretion to

apply a reenrollment bar period that is different from that indicated below (though which in no

case will be greater than 10 to 20 years).

• § 424.535(a)(1) (Noncompliance) – 1 year

• §424.535(a)(6) (Grounds Related to Screening) – 1 year

• §424.535(a)(11) (Initial Reserve Operating Funds) – 1 year

• §424.535(a)(23) (Provider/Supplier Standards) – 1 year

The following revocation reasons will receive reenrollment bar lengths per CMS discretion:

• §424.535(a)(1) (Noncompliance- Not Professionally Licensed Individual Practitioners)

• §424.535(a)(2) (Provider or supplier conduct)

• §424.535(a)(3) (Felonies)

• §424.535(a)(4) (False or misleading information)

• §424.535(a)(5) (On-site review)

• §424.535(a)(7) (Misuse of billing number)

• §424.535(a)(8) (Abuse of billing privileges)

• §424.535(a)(9) (Failure to Report)

• §424.535(a)(10) (Failure to document or provide CMS access to documentation)

• §424.535(a)(12) (Other program termination)

• §424.535(a)(13) (Prescribing authority)

• §424.535(a)(14) (Improper Prescribing Practices)

• §424.535(a)(15) (False Claims Act Civil Judgment)

• §424.535(a)(17) (Debt Referred to the United States Department of Treasury)

• §424.535(a)(18) (Revoked Under a Different Name, Numerical Identifier or Business

Identity)

• §424.535(a)(19) (Affiliation that Poses an Undue Risk)

• §424.535(a)(20) (Billing from a Non-Compliant Location)

• §424.535(a)(21) (Abusive ordering, certifying, referring, or prescribing of Part A or B

services, items, or drugs)

• §424.535(a)(22) (Patient Harm)

C. Applicability of Bar

1. Revocation Reasons Other Than § 424.535(a)(1), (a)(5), (a)(6), (a)(9), (a)(10), (a)(11), and

(a)(23).

In general, and unless stated otherwise above, any reenrollment bar at a minimum applies to: (1)

all practice locations under the provider’s PECOS or legacy enrollment record; and (2) any effort

to reestablish any of these locations (i) at a different address and/or (ii) under a different business

or legal identity, structure, or TIN. If the contractor receives an application and is unsure

whether a revoked provider is attempting to reestablish a revoked location, it shall contact its

PEOG BFL for guidance. Instances where the provider might be attempting to do so include -

but are not limited to – the following:

SCENARIO 1 - Smith was the sole owner of Group Practice X, a sole proprietorship. Six months

after X was revoked under § 424.535(a)(9), the contractor receives an initial application from

Group Practice Medicine, LLC, of which Smith is the sole owner/member.

SCENARIO 2 - Jones and Smith were 50 percent owners of World Home Health Agency, a

partnership. One year after World Home Health was revoked under § 424.535(a)(7), the

contractor receives an initial application from XYZ Home Health, a corporation owned by Jones

and spouse.

SCENARIO 3 - Smith was the sole owner of XYZ Medical Supplies, Inc. XYZ’s lone location

was at 1 Jones Street. XYZ’s billing privileges were revoked after it was determined that the site

was non-operational. Nine months later, the contractor receives an initial application from

Johnson Supplies, LLC. The entity has two locations in the same city in which 1 Jones Street is

located. Smith is listed as a 75 percent owner.

2. Revocation Reasons § 424.535(a)(1), (a)(5), (a)(6), (a)(9), (a)(10), (a)(11), and (a)(23)

For these revocation reasons, any reenrollment bar applies only to the specific enrollment that

was the subject of the reenrollment bar.

D. Discussing Provider Enrollment Appeals Process in Revocation Letter

(If a conflict exists between the instructions in this section 10.4.7.4(D) and those in either (i)

those in section 10.6.18 or (ii) the language in the applicable model letter in section 10.7 et seq.,

the guidance in section 10.6.18 or the model letter takes precedence.)

In the revocation letter, the contractor shall include information concerning the provider’s appeal

rights. The following table summarizes where the provider must send a corrective action plan

(CAP) and/or reconsideration request.

CAP requests should be sent to: Reconsideration request

should be sent to:

Revocation

Regulation

Institutional*

Non-institutional Institutional*

-Non-Institutional

424.535(a)(1)

related to an

enrollment

requirement (i.e.,

425.516)

Alone or in

combination:

CMS

MAC CMS MAC

424.535(a)(1)

Licensure

CAP rights (to

CMS)

CAP rights (to the

MAC)

CMS MAC

424.535(a)(1) DME or

IDTF

CAP rights (to

CMS)

CAP rights (to the

MAC)

CMS MAC

424.535(a)(2)

Exclusion

No CAP rights No CAP rights CMS CMS

424.535(a)(2)

Debarment

No CAP rights No CAP rights CMS CMS

424.535(a)(3) No CAP rights No CAP rights CMS CMS

424.535(a)(4) No CAP rights No CAP rights CMS CMS

424.535(a)(5) No CAP rights No CAP rights CMS MAC

424.535(a)(6) No CAP rights No CAP rights CMS MAC

424.535(a)(7) No CAP rights No CAP rights CMS CMS

424.535(a)(8) No CAP rights No CAP rights CMS CMS

424.535(a)(9) No CAP rights No CAP rights CMS MAC

424.535(a)(10) No CAP rights No CAP rights CMS CMS

424.535(a)(11) No CAP rights No CAP rights CMS CMS

424.535(a)(12) No CAP rights No CAP rights CMS CMS

424.535(a)(13) No CAP rights No CAP rights CMS CMS

424.535(a)(14) No CAP rights No CAP rights CMS CMS

424.535(a)(15) o No CAP rights o No CAP rights CMS CMS

424.535(a)(17) No CAP rights No CAP rights CMS CMS

424.535(a)(18) No CAP rights No CAP rights CMS CMS

424.535(a)(19) No CAP rights No CAP rights CMS CMS

424.535(a)(20) No CAP rights No CAP rights CMS CMS

424.535(a)(21) No CAP rights No CAP rights CMS CMS

424.535(a)(22) No CAP rights No CAP rights CMS CMS

424.535(a)(23) No CAP rights No CAP rights CMS CMS

* Institutional providers:

• Ambulance Service Supplier

• Ambulatory Surgery Centers

• CLIA Labs

• Community Mental Health Center

• Comprehensive Outpatient Rehabilitation Facilities (CORFs)

• Critical Access Hospitals

• End Stage Renal Disease (ESRDs)

• Federally Qualified Health Centers (FQHCs)

• Histocompatibility Laboratories

• Home Health Agencies

• Home Infusion Therapy Suppliers

• Hospices

• Hospitals and Hospital Units

• Independent Diagnostic Testing Facilities (IDTFs)

• Intensive Cardiac Rehabilitation

• Indian Health Service Facility

• Mammography Screening Centers

• Mass Immunization/Flu Roster Billers

• Medicare Diabetes Prevention Programs (MDPPs)

• Opioid Treatment Centers (OTPs)

• Organ Procurement Organizations (OPOs)

• Outpatient Physical Therapy/Outpatient Speech Pathology Services (OPT/OSP)

• Pharmacies

• Portable X-Ray Suppliers (PXRSs)

• Radiation Therapy Centers

• Rehabilitation Services

• Religious Non-Medical Health Care Institutions (RNCHIs)

• Rural Health Clinics (RHCs)

• Skilled Nursing Facilities (SNFs)

The CMS defines "institutional provider" in 42 CFR § 424.502 to mean any provider/supplier

that submits a paper Medicare enrollment application using the Form CMS-855A, Form CMS-

855B (except physician and non-physician practitioner organizations), or Form CMS-855S, or

the associated Internet-based PECOS enrollment application. (Note that MDPP suppliers no

longer fall within this regulatory definition of institutional provider. Per 42 CFR §

424.205(b)(5), the provider enrollment application fee is inapplicable to all MDPP suppliers that

submit a Form CMS-20134 enrollment application. Solely for purposes of appeal submissions,

however, MDPP suppliers are included in the bulleted list above.)