CMS Pub. 100-08, ch. 10, § 10.4.9.1

Note that the MAC will handle all non-DMEPOS supplier stay rebuttals consistent with the

instructions in this section 10.4.9.1 and all other CMS guidance. DMEPOS supplier stay

rebuttals will be handled by the PEOG Division of Provider Enrollment Appeals. All stay of

enrollment rebuttals for DMEPOS suppliers shall be forwarded to

providerenrollmentappeals@cms.hhs.gov within 5 days of receipt.

A. Background

Pursuant to 42 CFR § 424.541(b), a provider/supplier (hereafter “provider”) under a stay of

enrollment may file a rebuttal. A rebuttal is an opportunity for the provider to demonstrate that it

met all applicable enrollment requirements and that the stay should not have been imposed.

Only one rebuttal request may be submitted per enrollment stay. Additional rebuttal requests

submitted for the same stay for which a rebuttal has already been received shall be dismissed.

If the applicable CMS form (ACF) (see section 10.4.9) is received for a “stayed” provider while

a rebuttal submission is pending or during the rebuttal submission timeframe, the contractor shall

process the ACF consistent with current instructions.

The CMS’s Division of Provider Enrollment Appeals (DPEA) will handle all stay of enrollment

rebuttals for DMEPOS suppliers. Stay of enrollment letters for DMEPOS suppliers shall instruct

suppliers to files rebuttals with CMS. The Contractor shall forward all stay of enrollment

rebuttals for DMEPOS suppliers to ProviderEnrollmentAppeals@cms.hhs.gov within 10

calendar days of receipt. The Contractor shall not process the rebuttal if it is required to be

forwarded to CMS.

B. Rebuttal Submissions

1. Requirements and Submission of Rebuttals

Pursuant to 42 C.F.R. § 424.541(b), to be accepted and processed, the rebuttal submission

must—

(1) Be in writing;

(2) Specify the facts or issues concerning the rebuttal with which the provider disagrees, and

the reasons for disagreement;

(3) Include all documentation the provider wants CMS to consider in its review of the stay;

(4) Be submitted in the form of a letter that is signed and dated by the individual supplier (if

enrolled as an individual physician or nonphysician practitioner), the authorized official

or delegated official (as those terms are defined in 42 C.F.R. § 424.502), or a legal

representative (as defined in 42 C.F.R. § 498.10).

• If the legal representative is an attorney, the attorney must include a statement that the

attorney has the authority to represent the provider; this statement is sufficient to

constitute notice of such authority.

• If the legal representative is not an attorney, the provider must file with CMS written

notice of the appointment of a representative; this notice of appointment must be

signed and dated by, as applicable, the individual supplier, the authorized official or

delegated official, or a legal representative.

• Authorized or delegated officials for groups cannot sign and submit a rebuttal on

behalf of a reassigned provider without the provider submitting a signed statement

authorizing that individual from the group to act on the reassigned provider’s behalf.

• Signatures may be original or electronic. Valid signatures include handwriting (wet)

signatures in ink and digital/electronic signatures. Digital or electronic signatures

such as those created by digital signature options, created in software, such as Adobe)

and email signatures shall be accepted. Contractors shall contact

ProviderEnrollmentAppeals@cms.hhs.gov for questions regarding electronic and

digital signatures.

(5) Be received by the contractor within 15 calendar days from the date of the stay

notification letter to the provider. The contractor shall accept a rebuttal submission via

hard-copy mail, e-mail, and/or fax.

If the rebuttal submission is not appropriately signed or if a statement from the attorney or

written notice of representation is not included in the submission, the contractor shall send a

development request for a proper signature or the missing statement/written notice (using the

applicable model letter) before dismissing the rebuttal submission. The contractor shall allow 15

calendar days from the date of the development request letter for the rebuttal submitter to

respond to the development request.

If a rebuttal submission--(1) Is not appropriately signed and no response is received to the

development request (if applicable); (2) Is untimely (as described above); (3) Does not specify

the facts or issues with which the provider disagrees and the reasons for disagreement and no

response is received to the development request; or (4) Is a duplicative submission, the

contractor shall dismiss the rebuttal submission using the applicable rebuttal dismissal model

letter. (The contractor shall use the applicable model letter in section 10.7.20 of this chapter. If

the applicable model letter does not exist, the contractor should use the same rebuttal dismissal

letters applicable to deactivation letters, modifying them to apply to the stay situation.) For those

rebuttal submissions that are improperly signed and/or do not specify the facts or issues with

which the provider disagrees and the reasons for disagreement, the contractor shall send a

development request via hard-copy mail, email, if available, to the provider requesting a proper

signature and/or clarification on the facts or issues with which the provider disagrees and the

reasons for disagreement using the applicable rebuttal development model letter. Sending the

development letter via fax is optional. The contractor shall grant an additional 15-calendar days

from the date of the development request letter for the provider to submit an acceptable rebuttal

submission. If no response is received or the rebuttal submission is still deficient after the

development request and the 15-calendar day timeframe has expired, the contractor shall dismiss

the rebuttal submission using the applicable rebuttal dismissal model letter.

The contractor may make a good cause determination to accept any rebuttal that has been

submitted beyond the 15 calendar-day filing timeframe. Good cause may be found where there

are circumstances beyond the provider’s control that prevented the timely submission of a

rebuttal. These uncontrollable circumstances do not include the provider’s failure to timely

update its enrollment information, specifically its various addresses. If the contractor believes

good cause exists to accept an untimely rebuttal submission, the contractor shall send a request

approval email to ProviderEnrollmentAppeals@cms.hhs.gov within five calendar days of

making the good cause determination. This email shall detail the contractor’s reasoning for

finding good cause. Processing timeliness standards shall begin on the date the contractor

receives a response from CMS.

2. Time Calculations for Rebuttal Submissions

If the 15th calendar day from the date of the stay notification letter falls on a weekend or

federally-recognized holiday, the rebuttal shall be accepted as timely if the contractor received it

by the next business day.

It is the provider’s responsibility to timely update the provider’s enrollment record to reflect any

changes to the provider’s enrollment information including, but not limited to, the

correspondence address. Failure to timely update a correspondence address or other addresses

included in the Medicare enrollment record does not constitute an “in fact” showing that the stay

notice was received after the presumed receipt date (as described above).

3. Processing Rebuttal Submissions

The contractor shall send an acknowledgement letter via hard-copy mail to the return address on

the rebuttal submission within 10 calendar-days of receipt of the accepted rebuttal request using

the rebuttal acknowledgment model letter, including a rebuttal tracking number and the

provider’s NPI. The acknowledgement letter shall also be sent via email if a valid email address

is available (either in the enrollment record or rebuttal submission). It is optional for the

contractor to send the acknowledgement letter via fax if a valid fax number is available. If a

rebuttal determination is issued within 10 calendar-days of the date of receipt of the rebuttal

submission, the contractor is not required to issue a receipt acknowledgement letter.

The contractor shall process all accepted rebuttal submissions within 30 calendar days of the date

of receipt. If, while reviewing the rebuttal submission, the provider wishes to withdraw its

rebuttal, the request to withdraw must be submitted to the contractor in writing before the

rebuttal determination is issued. If a provider submits a written request to withdraw its rebuttal

submission prior to the issuance of a rebuttal determination, the contractor shall issue a letter

using the applicable rebuttal withdrawn model letter and no rebuttal determination shall be

issued.

All materials received from the provider shall be considered by the contractor in its review.

4. Reason-Specific Instructions

As explained in section 10.4.9, CMS may impose a stay if the following two requirements are

met:

• The provider is non-compliant with at least one enrollment requirement in Title 42; and

• The provider can remedy the non-compliance via the submission of, as applicable to the

situation, a Form CMS-855, Form CMS-20134, or Form CMS-588 change of information

or revalidation application (hereafter collectively referenced as “the applicable CMS

form” or “ACF”.)

In its review, therefore, the contractor shall, as a general principle, ascertain whether the provider

(1) was indeed non-compliant and (2) can remedy the non-compliance by submitting an ACF.

The contractor can review section 10.4.8.1(C)(4) (which addresses deactivation rebuttals) and

apply the same basic principles discussed in those illustrations to their factually corresponding

stay rebuttal situations.

Note that for stay rebuttals other than that discussed in Example (ii)(A) below, the contractor

may need additional information (beyond that referenced in section 10.4.9(A)) regarding

PEOG’s decision to impose a stay. In such cases, the contractor shall contact

ProviderEnrollmentRevocations@cms.hhs.gov and clearly outline the requested data. The 30-day timeframe for processing the rebuttal stops between the times the contractor sends the

request and receives the information from PEOG.

C. Determination

The contractor shall render a determination regarding a rebuttal submission using the appropriate

model rebuttal decision letter. If the contractor is unable to render a determination, the contactor

shall use the appropriate model letter for the specific situation. All determinations (including

dismissals and withdrawals) related to rebuttal submissions shall be sent (1) via hard-copy mail

to the return address on the rebuttal submission; (2) via hard-copy mail to the correspondence

mailing address on the enrollment records (if different from return address on rebuttal

submission); and (3) by e-mail if a valid e-mail address is available (submitted as part of the

rebuttal submission and/or listed in the enrollment record correspondence mailing address). The

contractor may also send via fax if a valid fax number is available. All documentation shall be

saved in PDF format. All notification letters shall be mailed on the same date listed on the letter.

If the contractor issues a rebuttal determination favorable to the provider, it shall make the

necessary modification(s) to the provider’s enrollment within 5 calendar days of the date of the

favorable determination letter. This will involve a rescission of the stay regardless of whether

the stay has already been lifted or is still in effect. If the contractor confirms that the ACF is not

needed and that no new changes are being reported, the contractor shall use the following return

reason in the returned application model letter found in section 10.7.7 of this chapter: “A rebuttal

decision has been issued; therefore, the submitted Form CMS [855/588/20134] is not needed.” If

new changes were being reported as part of the ACF, the contractor shall process those changes.

If the contactor issues a rebuttal determination unfavorable to the provider, the stay (irrespective

of whether it has been lifted) remains intact. Hence, if a stay existed from March 1 to March 10

and the stay was upheld on April 1, the record shall still reflect that the provider was under a stay

between March 1 – 10.

D. No Further Review

Pursuant to § 424.541(b)(6), a determination made regarding a stay rebuttal request is not an

initial determination and is not subject to further review. Thus, no additional appeal rights shall

be included on any rebuttal determination letter.

E. External Monthly Reporting for Stay Rebuttals

(This data shall be reported in a template separate from that concerning deactivation rebuttals per

section 10.4.8.1. of this chapter.)

Using the provider enrollment rebuttals reporting template, the contractor shall complete all

columns listed for all stay rebuttal submissions received and processed by the contractor. No

column shall be left blank (except Column K, as described below and as applicable). If the

contractor is unable to complete all columns for a given rebuttal submission, the contractor shall

contact ProviderEnrollmentAppeals@cms.hhs.gov within five business days of discovery to seek

further guidance.

The reports shall use only the formats identified below. All dates shall be formatted as

mm/dd/yyyy (e.g., 01/13/2021). The reports shall be sent to CMS via email at

ProviderEnrollmentAppeals@cms.hhs.gov no later than the 15th of each month. If this day falls

on a weekend or a holiday, the report shall be submitted the following business day. The report

shall include the prior month’s rebuttal submissions, as well as outcomes for all submissions

previously received that were not yet completed and reported to CMS (e.g., the February report

shall cover all January rebuttals).

IMPORTANT: All submissions shall remain on the monthly report until a final

outcome/decision has been reported to CMS.

• Column A: The response in Column A labelled, “Provider/Supplier Name” shall be the

legal business name of the provider/supplier, exactly as it is spelled and formatted in the

PECOS enrollment record (including capitalization, abbreviations, and punctuation). This

column shall not be blank.

• Column B: The response in Column B labelled “NPI” shall be the provider’s or

supplier’s NPI. If a provider/supplier has multiple NPIs, each shall be separated with a

semicolon followed by a space (e.g. “1234567890; 1123456789”). This column shall not

be blank.

• Column C: The response in Column C labelled, “EID” shall be the provider’s or

supplier’s EID PECOS enrollment identification number (EID) as it appears in PECOS.

On the rare occasion that no EID is available, the contractor shall enter “N/A”. This

column shall not be blank.

• Column D: The response in Column D labelled, “PTAN(s)” shall be the provider’s or

supplier’s Provider Transaction Access Number(s) (PTAN(s)), or other Medicare ID

number. If the provider/supplier has not yet been assigned a PTAN or Medicare ID, the

contractor shall enter “N/A”. This column shall not be blank.

• Column E: The response in Column E labelled, “Contractor,” shall be in one of the

following formats, as appropriate. This column shall not be blank. No other formats are

acceptable.

o CGS

o FCSO

o NGS JK

o NGS J6

o Palmetto JM

o Palmetto JJ

o NSC

o WPS J8

o WPS J5

o Noridian JE

o Noridian JF

o Novitas JL

o Novitas JH

o NPEast

o NPWest

• Column F: The response in Column F labelled “Non-Compliance” shall briefly describe

the non-compliance that led to the stay (e.g., revalidation non-response). This column

shall not be blank.

• Column G: The response in Column G labelled, “Date Received” shall be the date on

which the Contractor received the rebuttal. The date shall be formatted as mm/dd/yyyy

(e.g. 10/25/2021); no other formats are acceptable. This column shall not be blank.

• Column H: The response in Column H labelled, “Date Receipt Acknowledgement Sent,”

shall be one of the following:

o [mm]/[dd]/[yyyy]

The date the receipt acknowledgement email/letter was sent to the

provider/supplier or the representative, in “mm/dd/yyyy” format. No other date

formats are acceptable.

o Not Yet Sent

If a receipt acknowledgement email/letter has not been sent to the

provider/supplier/legal representative at the time the monthly report is sent to

CMS.

o N/A

If a receipt acknowledgement email/letter is not required for that case (i.e.,

rebuttal determination is issued within 10-calendar days of the date of receipt of

the rebuttal submission).

• Column I: The response in Column I labelled, “Date Final Decision Issued” shall be the

date on which the Contractor issues the rebuttal determination. The date shall be

formatted as mm/dd/yyyy (e.g. 09/19/2019). If a final rebuttal determination has not yet

been issued, the contractors shall enter "In Process" as the response. No other formats are

acceptable. This column shall not be blank.

• Column J: The response in Column J labelled, “Final Decision Result,” shall be one of

the following. No other formats are acceptable.

o Not Actionable

Rebuttal is no longer actionable (moot) because the basis for the stay has been

resolved (e.g., CMS rescinded the stay).

o Favorable

Contractor has determined that an error was made in the implementation of the

stay. Therefore, the initial determination was overturned and the stay has been

removed.

o Unfavorable

Contractor upholds the initial stay determination.

o Dismissed

The rebuttal submission does not meet the rebuttal submission requirements (e.g.

missing proper signature and did not timely respond to development request).

o Withdrawn

Provider/supplier/representative has submitted written notice of its intent to

withdraw its rebuttal before the contractor issued a determination and the

contractor has acknowledged the withdrawal.

o In Process

A final decision has not been issued. The contractor is still processing the

submission.

• Column K: The response in Column K labelled, “Comments,” shall include any

information related to the stay, rebuttal submission, or rebuttal determination that

provides context for CMS in reporting the rebuttal and outcome. This column may be left

blank if no additional information is necessary.