CMS Pub. 100-08, ch. 10, § 10.7.10

A. CAP Withdrawn Acknowledgement Template

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

1. Email Template

To: [Email address provided by the person who submitted the CAP]

Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]

Dear [Name of the person(s) who submitted the CAP]:

We are in receipt of your written withdrawal request in regard to your corrective

action plan (CAP) received on [Month] [DD], [YYYY]. [MAC Name] has not yet

issued a decision regarding your CAP. Therefore, [MAC Name] considers your CAP

dated [Month] [DD], [YYYY] to be withdrawn. As a result, a decision will not be

issued in response to your CAP.

If you have not yet filed a reconsideration request, please be advised that failure to

timely submit a reconsideration request is deemed a waiver of all further

administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

2. Hard-Copy Letter Template

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

We are in receipt of your written withdrawal request in regard to your corrective

action plan (CAP) received on [Month] [DD], [YYYY]. [MAC Name] has not yet

issued a decision regarding your CAP. Therefore, [MAC Name] considers your CAP

dated [Month] [DD], [YYYY] to be withdrawn. As a result, a decision will not be

issued in response to your CAP.

If you have not yet filed a reconsideration request, please be advised that failure to

timely submit a reconsideration request is deemed a waiver of all further

administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

B. CAP Receipt Acknowledgement Email Template to Provider/Supplier/

Representative

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

1. Email Template

To: [Email address provided by the person who submitted the CAP]

Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]

Dear [Name of the person(s) who submitted the CAP]:

We are in receipt of your corrective action plan (CAP) on behalf of

[Provider/Supplier Name]. Please be advised that [MAC Name] has 60 calendar

days to review your CAP and render a decision.

If you have additional information that you would like a hearing officer to consider

during the CAP review, you must submit that information prior to a decision being

issued.

Please be advised that failure to timely submit a reconsideration request is deemed

a waiver of all further administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely

,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

2. Hard-Copy Letter Template

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

We are in receipt of your corrective action plan (CAP) on behalf of

[Provider/Supplier Name]. Please be advised that [MAC Name] has 60 calendar

days to review your CAP and render a decision.

If you have additional information that you would like a hearing officer to consider

during the CAP review you must submit that information prior to a decision being

issued.

Please be advised that failure to timely submit a reconsideration request is deemed

a waiver of all further administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

C. CAP Decision Email Template to Provider/Supplier/Representative

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

To: [Email address provided by the person who submitted the CAP]

Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]

(Be sure to attach a copy of the final decision[s] in PDF format.)

Dear [Name of the person(s) who submitted the CAP]:

Please see the attached decision regarding your Medicare Provider Enrollment CAP.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

D. CAP Not Actionable (Moot) Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the CAP received by [MAC Name] based on the initial

determination letter, dated [Month] [DD], [YYYY].

In correspondence dated [Month] [DD], [YYYY], the initial determination letter,

dated [Month] [DD], [YYYY] informing you of the [denial of your Medicare

enrollment application or revocation of your Medicare billing privileges] was [insert

description] (des cribe action taken in regards to the initial determination, i.e.

rescission of denial or revocation). For your convenience, a copy of the initial

determination is included. Therefore, the issue set forth in the CAP is no longer

actionable. This issue is moot, and we are unable to render a decision on the matter.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

E. Untimely CAP Dismissal Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the CAP received by [MAC Name] based on the initial

determination letter, dated [Month] [DD], [YYYY].

[MAC Name] is unable to accept your CAP as it was not timely submitted. The

initial determination letter was dated [Month] [DD], [YYYY]. A CAP must be

received within 35 calendar days of the date of the initial determination letter. Your

CAP was not received until [Month] [DD], [YYYY], which is beyond the applicable

submission time frame. [Provider/Supplier/Representative] failed to show good

cause for its late request. Therefore, [MAC Name] is unable to render a decision in

this matter.

Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for

instructions on how to properly file a reconsideration request. If you have already

submitted a reconsideration request, you will receive further communication related

to tha t submission. Failure to timely file a reconsideration request is deemed a

waiver of all further administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

F. Improperly Signed CAP Dismissal Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on the initial determination letter, dated [Month] [DD], [YYYY].

[MAC Name] is unable to accept your CAP as it was not signed by an authorized or

delegated official currently on file in your Medicare enrollment record, the

individual provider or supplier, or a properly appointed representative. The

signature requirement was stated in the initial determination letter, dated [Month]

[DD], [YYYY], as well as in Chapter 10 of the Medicare Program Integrity Manual.

Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for

instructions on how to properly file a reconsideration request. If you have already

submitted a reconsideration request, you will receive further communication related

to that submission. Failure to timely file a reconsideration request is deemed a

waiver of all further administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

G. No CAP Rights Dismissal Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on the initial determination letter, dated [Month] [DD], [YYYY].

[MAC Name] is unable to accept your CAP. A provider or supplier may only submit

a CAP if there has been a denial of enrollment in the Medicare program under 42

C.F.R § 424.530(a)(1) or the revocation of Medicare billing privileges under 42

C.F.R. § 424.535(a)(1). Your enrollment was not denied or revoked under one of

the aforementioned authorities. Therefore, a CAP decision cannot be rendered based

on this submission.

Please refer to the initial determination letter, dated [Month] [DD], [YYYY], for

instructions on how to properly file a reconsideration request. If you have already

submitted a reconsideration request, you will receive further communication related

to that submission. Please be advised that failure to timely submit a reconsideration

request is deemed a waiver of all further administrative review.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

H. Not Eligible to Submit CAP Dismissal Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the [corrective action plan (CAP)] received by [MAC

Name], based on the [Month] [DD], [YYYY] initial determination.

[MAC Name] is unable to accept your [CAP] submission because the action taken in

regards to your Medicare enrollment is not an initial determination subject to

administrative review. More specifically, an initial determination has not been made

as described in 42 C.F.R. § 498.3(b). Under 42 C.F.R. § 498.5(l), appeal rights

extend only to initial determinations related to the denial or revocation of Medicare

billing privileges.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

I. CAP Signature Development Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

We are in receipt of your CAP submission, received on [Month] [DD], [YYYY].

(If the submission is not properly signed, use the following.) [Your submission is

not appropriately signed, as stated in the initial determination letter and in the

Medicare Program Integrity Manual, Ch. 10, Section 10.6.18. [MAC Name] is

requesting that you submit a CAP that is properly signed by the individual provider,

supplier, the authorized or delegated official, or a properly appointed representative.

Your properly signed submission must be received within 15 calendar days of the

date of this notice. If you do not timely respond to this request, your CAP submission

may be dismissed.]

(If the submission is missing a statement by the attorney, use the following.) [Your

submission is missing an attorney statement that the attorney has the authority to

represent the provider or supplier. [MAC Name] is requesting that you submit a

CAP that includes an attorney statement that the attorney has the authority to

represent the provider or supplier within 15 calendar days of the date of this notice.

If you do not timely respond to this request, your CAP submission may be

dismissed.]

(If the submission is missing a signed written notice from the provider/supplier

authorizing the representative to act on the provider’s/supplier’s behalf, use the

following.) [Your submission is missing a written notice of the appointment of a

representative signed by the provider or supplier. [MAC Name] is requesting that

you submit written notice of the appointment of a representative that is signe d by

the provider or supplier within 15 calendar days of the date of this notice. If you do

not timely respond to this request, your CAP submission may be dismissed.]

Your submission should be sent to [MAC Appeal Receipt Email Address] or mailed

to the following address:

[MAC Appeal Receipt Address] [MAC Fax number]

If you have any questions, please contact our office at [phone number] between the

hours of [x:00 AM/PM] and [x:00 AM/PM].

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

J. Favorable CAP Model Letter in Response to an Enrollment Denial

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Name of the person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on an enrollment denial. The initial determination letter was dated

[Month] [DD], [YYYY] and the CAP was received on [Month] [DD], [YYYY];

therefore, this CAP is co nsidered timely. (if the CAP is untimely, but good cause

has been found to accept the CAP, use the following [This CAP was not timely

submitted, but a good cause waiver has been granted.) The following decision is

based on the Social Security Act (Act), Me dicare regulations, the CMS manual

instructions, the Medicare enrollment record, and any information received before

this decision was rendered.

DENIAL REASON:

• 42 C.F.R. § 424.530(a)(1)

OTHER APPLICABLE AUTHORITIES:

• (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX)

EXHIBITS:

• Exhibit 1: (Ex.: CAP, signed by Doe, dated [Month] [DD], [YYYY].)

• Exhibit 2: (Ex: Copy of a medical license for Doe from the Wisconsin

Medical Board, effective [Month] [DD], [YYYY].)

(In this section list each document submitted by the provider or supplier. Each

exhibit should include the date, as well as a brief description of the document. You

shall also include all other documentation not submitted by the provider that the

hearing o fficer reviewed in making the decision, e.g., enrollment applications,

development letters, etc.)

BACKGROUND:

The documentation related to the matter for [Provider/Supplier Name] has been

reviewed and the decision has been made in accordance with the applicable

Medicare rules, policies and program instructions.

(Summarize the facts underlying the case which led up to the submission of the

CAP.)

CORRECTIVE ACTION PLAN ANALYSIS:

[A [Provider/Supplier Name] may only submit a corrective action plan for

noncompliance under 42 C.F.R. § 424.530(a)(1). If the initial determination was

based on any other denial reasons other than 42 C.F.R. § 424.530(a)(1), this decision

will not review those authorities.]

(A CAP is an opportunity to correct the deficiencies identified in the initial

determination. This section should include: A clear explanation of why the denial

was overturned in sufficient detail for the provider or supplier to understand the

decision and; if applicable: the nature of the provider or supplier’s deficiencies, the

regulatory or other policy basis to support each reason for the denial, and an

explanation of how the provider or supplier now meets the enrollment criteria or

requirements. This s ection shall not reference a CAP decision without explaining

how and why you came to that decision.)

DECISION:

(A short conclusory restatement. Approval date should be based on the date the

provider or supplier came into compliance with all applicable Medicare

requirements.)

(Ex: On [Month] [DD], [YYYY], Doe’s medical license expired. However, on

[Month] [DD], [YYYY] Smith submitted a copy of the renewed medical license,

which was reinstated back to the date of expiration by the Wisconsin Medical Board.

As a result, [MAC Name] finds that Doe came into compliance with the applicable

Medicare requirements on [Month] [DD], [YYYY]. Therefore, [MAC Name]

overturns the denial of Doe’s Medicare enrollment application as it relates to 42

C.F.R. § 424.530(a)(1).

This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC

name] will continue processing the enrollment application.

(If additional information is needed from the provider or supplier in order to

reactivate the enrollment, the MAC shall state what information is needed

from the provider or supplier in this CAP decision. MACs shall state that the

requested information/documentation must be received within 30 calendar

days of the date of this decision letter.)

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

K. Favorable CAP Model Letter for Revocation Determination

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on a revocation of Medicare billing privileges. The initial

determination letter was dated [Month] [DD], [YYYY] and the CAP was received

by [MAC Name] on [Month] [D D], [YYYY]; therefore, this appeal is considered

timely. (if the CAP is untimely, but good cause has been found to accept the CAP,

use the following [This CAP was not timely submitted, but a good cause waiver has

been granted.]) The following decision is based on the Social Security Act (Act),

Medicare regulations, the CMS manual instructions, evidence in the file, and any

information received before this decision was rendered.

REVOCATION REASON:

• 42 C.F.R. § 424.535(a)(1)

OTHER APPLICABLE AUTHORITIES:

• (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX)

EXHIBITS:

• Exhibit 1: (Ex.: CAP, signed by Doe, dated [Month] [DD], [YYYY].)

• Exhibit 2: (Ex: Copy of a medical license for Doe from the Wisconsin

Medical Board, effective [Month] [DD], [YYYY].)

(In this section list each document submitted by the provider or supplier. Each

exhibit should include the date, as well as a brief description of the document. You

shall also include all other documentation not submitted by the provider that the

hearing o fficer reviewed in making the decision, e.g., enrollment applications,

development letters, etc.)

BACKGROUND:

The documentation related to the matter for [Provider/Supplier Name] has been

reviewed and the decision has been made in accordance with the applicable

Medicare rules, policies, and program instructions.

(Summarize the facts underlying the case which led up to the submission of the

CAP.)

CORRECTIVE ACTION PLAN ANALYSIS:

[A [Provider/Supplier Name] may only submit a corrective action plan for

noncompliance. If the initial determination was based on revocation reasons other

than 42 C.F.R. § 424.535(a)(1), this decision will not review those authorities.]

(A CAP is an opportunity to correct the deficiencies identified in the initial

determination. This section should include: A clear explanation of why the

revocation is being upheld or overturned in sufficient detail for the provider or

supplier to understand the decision and; if applicable: the nature of the provider or

supplier’s deficiencies, the regulatory basis to support the revocation for

noncompliance, and an explanation of how the provider or supplier now meets the

enrollment compliance criteria or requirements. This section shall not reference a

CAP decision without explaining how and why you came to that decision.)

DECISION:

(A short conclusory restatement.)

(Ex: On [Month] [DD], [YYYY], Doe’s medical license was suspended. However,

as part of a CAP, Doe submitted a revised order from the Wisconsin Medical Board,

which reinstated the medical license back to the date of suspension. As a result,

[MAC Name] finds that Doe came into compliance with the applicable Medicare

requirements on [Month] [DD], [YYYY]. Therefore, [MAC Name] overturns the

revocation of Doe’s Medicare billing privileges as it relates to 42 C.F.R. §

424.535(a)(1).

This decision is a FAVORABLE DECISION. To effectuate this decision, [MAC

name] [will reinstate/has reinstated] your Medicare billing privileges, effective

[Month] [DD], [YYYY].

(The reinstatement date is based on chapter 10 of the MPIM and the date of the

provider’s or supplier’s revocation or the date the provider’s or supplier’s license

was reinstated if the revocation involves a licensure issue.)

(If additional information is needed from the provider or supplier in order to

reactivate the enrollment, the MAC shall state what information is needed

from the provider or supplier in this CAP decision. MACs shall state that the

requested information/documentation must be received within 30 calendar

days of the date of this decision letter.)

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

L. Unfavorable CAP Model Letter in Response to an Enrollment Denial

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on an enrollment denial. The initial determination letter was dated

[Month] [DD], [YYYY] and the CAP was received by [MAC Name] on [Month]

[DD], [YYYY]; therefore, this appeal is considered timely. (if the CAP is untimely,

but good cause has been found to accept the CAP, use the following [This CAP was

not timely submitted, but a good cause waiver has been granted.])The following

decision is based on the Social Security Act (Act), Medicare regulations, the CMS

manual instructions, the Medicare enrollment record, and any information received

before this decision was rendered.

DENIAL REASON:

• 42 C.F.R. § 424.530(a)(1)

OTHER APPLICABLE AUTHORITIES:

• (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX)

EXHIBITS:

• Exhibit 1: (Ex.: (Ex.: CAP, signed by Doe, dated [Month] [DD], [YYYY].)

• Exhibit 2: (Ex: Copy of a medical license for Doe from the Wisconsin

Medical Board, effective [Month] [DD], [YYYY].)

(In this section list each document submitted by the provider or supplier. Each

exhibit should include the date, as well as a brief description of the document. You

shall also include all other documentation not submitted by the provider that the

hearing o fficer reviewed in making the decision, e.g., enrollment applications,

development letters, etc.)

BACKGROUND:

The documentation related to the matter for [Provider/Supplier Name] has been

reviewed and the decision has been made in accordance with the applicable

Medicare rules, policies, and program instructions.

(Summarize the facts underlying the case which led up to the submission of the

CAP).

CORRECTIVE ACTION PLAN ANALYSIS:

[A [Provider/Supplier Name] may only submit a corrective action plan for

noncompliance under 42 C.F.R. § 424.530(a)(1). If the initial determination was

based on any other denial reasons other than 42 C.F.R. § 424.530(a)(1), this decision

will not review those authorities.]

(A CAP is an opportunity to correct the deficiencies identified in the initial

determination. This section should include: A clear explanation of why the denial is

being upheld in sufficient detail for the provider or supplier to understand the

decision and; if applicable: the nature of the provider or supplier’s deficiencies, the

regulatory or other policy basis to support each reason for the denial, and an

explanation of how the provider or supplier now meets the enrollment criteria or

requirements. This section shall not reference a CAP decision without explaining

how and why you came to that decision.)

DECISION:

(A short conclusory restatement.)

(On [Month] [DD], [YYYY], Doe’s medical license was suspended by the

Wisconsin Medical Board. [MAC Name] has confirmed that Doe’s medical license

remains suspended. As a result, [MAC Name] upholds the denial of Doe’s Medicare

enrollment application under 42 C.F.R. § 424.530(a)(1).)

This decision is an UNFAVORABLE DECISION. [MAC name] concludes that the

CAP does not correct the deficiencies that led to the denial of your Medicare

enrollment. As a result, the denial of your Medicare enrollment is upheld.

Failure to timely file a reconsideration request is deemed a waiver of all further

administrative review. However, if you have submitted a reconsideration request, a

separate decision is forthcoming.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

M. Unfavorable CAP Model Letter for Revocation Determination

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP]

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: Corrective Action Plan Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (optional)

Dear [Person(s) who submitted the CAP]:

This letter is in response to the corrective action plan (CAP) received by [MAC

Name] based on a revocation of Medicare billing privileges. The initial

determination letter was dated [Month] [DD], [YYYY] and the CAP was received

by [MAC Name] on [Month] [D D], [YYYY]; therefore, this appeal is considered

timely. (if the CAP is untimely, but good cause has been found to accept the CAP,

use the following [This CAP was not timely submitted, but a good cause waiver has

been granted.]) The following decision is based on the Social Security Act (Act),

Medicare regulations, the CMS manual instructions, the Medicare enrollment

record, and any information received before this decision was rendered.

REVOCATION REASON:

• 42 C.F.R. § 424.535(a)(1)

OTHER APPLICABLE AUTHORITIES:

• (Ex: Medicare Program Integrity Manual chapter 10, section 10.XX)

EXHIBITS:

• Exhibit 1: (Ex.: (Ex.: CAP, signed by Doe, dated [Month] [DD], [YYYY].)

• Exhibit 2: (Ex: Copy of a medical license for Doe from the Wisconsin

Medical Board, effective [Month] [DD], [YYYY].)

(In this section list each document submitted by the provider or supplier. Each

exhibit should include the date, as well as a brief description of the document. You

shall also include all other documentation not submitted by the provider that the

hearing o fficer reviewed in making the decision, e.g., enrollment applications,

development letters, etc.)

BACKGROUND:

The documentation related to the matter for [Provider/Supplier Name] has been

reviewed and the decision has been made in accordance with the applicable

Medicare rules, policies, and program instructions.

(Summarize the facts underlying the case which led up to the submission of the

CAP.)

CORRECTIVE ACTION PLAN ANALYSIS:

[A [Provider/Supplier Name] may only submit a corrective action plan for

noncompliance. If the initial determination was based on revocation reasons other

than 42 C.F.R. § 424.535(a)(1), this decision will not review those authorities.]

(A CAP is an opportunity to correct the deficiencies identified in the initial

determination. This section should include: A clear explanation of why the

revocation is being upheld in sufficient detail for the provider/supplier to understand

the decision and, if applicable: the nature of the provider/supplier’s deficiencies, the

regulatory or other policy basis to support compliance and how the provider/supplier

now meets the enrollment criteria or requirements. This section shall not reference

a CAP decision without explaining how and why you came to that decision.)

DECISION:

(A short conclusory restatement.)

(On [Month] [DD], [YYYY], Doe’s medical license was suspended by the

Wisconsin Medical Board. Doe has not submitted evidence to demonstrate that the

medical license has been reinstated. In addition, [MAC Name] has confirmed that

Doe’s medical license remains suspended. As a result, [MAC Name] upholds the

revocation of Doe’s Medicare billing privileges under 42 C.F.R. § 424.535(a)(1).)

This decision is an UNFAVORABLE DECISION. [MAC name] concludes that

the CAP did not correct the deficiencies noted in the implementation of the

revocation. As a result, the revocation of your Medicare billing privileges is upheld.

Failure to timely file a reconsideration request is deemed a waiver of all further

administrative review. However, if you have submitted a reconsideration request, a

separate decision is forthcoming.

If you have any further questions, please forward your inquiries to [MAC Appeal

Receipt Email Address] or mail it to the following address:

[MAC Appeal Receipt Address] [Call Center Telephone Number]

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]

N. CAP Further Information Required for Development Model Letter

(To be sent by hard- copy mail and email if email address is provided. Optional to

send via fax if a valid fax number is available).

To: [Email address provided by the person who submitted the CAP.]

Subject: Medicare Provider Enrollment CAP re: [Provider/Supplier Name]

Dear [Name of the person(s) who submitted the CAP]

[Month] [DD], [YYYY]

[Provider/Supplier/Attorney/Firm Name]

Attn: [Signer/Submitter of CAP] (If submitted on behalf of an organization or

group)

[Address] (Address from which the CAP was sent)

[City], [State] [Zip Code]

Re: CAP Decision

Legal Business Name: [Provider/Supplier Name] (as it appears in PECOS)

NPI: [XXXXXXXXXX]

PTAN: [XXXXX]

Reference Number: [XXXX] (Internal Tracking)

Dear [Name of the person(s) who submitted the CAP]:

On [Month] [DD]. [YYYY], [MAC Name] issued a CAP decision. As stated in the

[Month] [DD], [YYYY] CAP decision letter, the approval of [Provider/Supplier

Name]’s Medicare enrollment is contingent upon the submission of [list required

documentation]. Please send the required documentation within 30 calendar days to:

[MAC CAP Receipt Address]

[MAC CAP Receipt Email Address] [MAC CAP Receipt Fax Number]

If you have any questions, please contact our office at [phone number] between the

hours of [x:00 AM/PM] and [x:00 AM/PM].

Sincerely,

[Signature of Hearing Officer] (May be electronic)

[Name of Hearing Officer]

[Position of Hearing Officer]

[MAC Name]