CMS Pub. 100-08, ch. 10, § 10.7.4

A. Approval – Change of Information (DME)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City, State, Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier],

[Insert Contractor] approved your Change of Information (COI) application.

Medicare Enrollment Information

Supplier Legal Business Name (LBN)

Doing Business As (DBA)

Physical Location Address

Supplier Type

National Provider Identifier (NPI)

Provider Transaction Access Number (PTAN)

PTAN Effective Date

Changed Information Include detailed changes or section titles, as

applicable.

Your PTAN is the authentication element for all inquiries to customer service representatives

(CSRs), written inquiry units, and the interactive voice response (IVR) system.

Filing claims electronically? Contact the Common Electronic Data Exchange (CEDI) Contractor

at www.ngscedi.com or (866) 311-9184.

Subscribe to receive timely listserv messages regarding Medicare billing policies at:

• Jurisdiction A – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme

• Jurisdiction B – CGS, www.cgsmedicare.com

• Jurisdiction C – CGS, www.cgsmedicare.com

• Jurisdiction D – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme

Enroll, make changes or view your existing enrollment information by logging into PECOS at

https://pecos.cms.hhs.gov.

Submit updates and changes to your enrollment information within the timeframes specified at

42 CFR § 424.516. For more information on the reporting requirements, go to Medicare

Learning Network Article SE1617.

Find additional Medicare program information, including billing, fee schedules, and Medicare

policies and regulations at [insert contractor’s web address] or https://www.cms.gov.

For questions concerning this letter, contact [Insert Contractor] at [contact information].

Sincerely,

[Name]

[Title]

[Company]

B. Approval – Initial (DME)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City, State, Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier],

[Insert Contractor] approved your initial enrollment application.

Medicare Enrollment Information

Supplier Legal Business Name (LBN)

Doing Business As (DBA)

Physical Address Location

Supplier Type

National Provider Identifier (NPI)

Provider Transaction Access Number (PTAN)

PTAN Effective Date

Participation Status

Your PTAN is the authentication element for all inquiries to customer service representatives

(CSRs), written inquiry units, and the interactive voice response (IVR) system.

Filing claims electronically? Contact the Common Electronic Data Exchange (CEDI) Contractor

at www.ngscedi.com or (866) 311-9184.

Subscribe to receive timely listserv messages regarding Medicare billing policies at:

• Jurisdiction A – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme

• Jurisdiction B – CGS, www.cgsmedicare.com

• Jurisdiction C – CGS, www.cgsmedicare.com

• Jurisdiction D – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme

Enroll, make changes or view your existing enrollment information by logging into PECOS at

https://pecos.cms.hhs.gov.

Submit updates and changes to your enrollment information within the timeframes specified

at 42 CFR §424.516. For more information on the reporting requirements, go to Medicare

Learning Network Article SE1617.

Find additional Medicare program information, including billing, fee schedules, and Medicare

policies and regulations at [insert contractor’s web address] or https://www.cms.gov.

Right to Submit a Reconsideration Request:

You may request a reconsideration of this determination. This is an independent review

conducted by a person not involved in the initial determination. (Optional Coversheet sentence

[To facilitate the processing of your reconsideration request, please utilize and include the

[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.])

Reconsideration requests must:

• Be received in writing within 65 calendar days of the date of this letter and mailed or emailed

to the address below.

• State the issues or findings of fact with which you disagree and the reasons for

disagreement.

• Be signed by the provider or supplier, an authorized or delegated official that has been

reported within your Medicare enrollment record, or an authorized representative.

o If the authorized representative is an attorney, the attorney’s statement that the attorney

has the authority to represent the provider or supplier is sufficient to accept this

individual as the representative.

o If the authorized representative is not an attorney, the individual provider, supplier, or

authorized or delegated official must file written notice of the appointment of a

representative with the submission of the reconsideration request.

o Authorized or delegated officials for groups cannot sign and submit a reconsideration

request on behalf of a reassigned provider/supplier without the provider/supplier

submitting a signed statement authorizing that individual from the group to act on the

reassigned provider’s/supplier’s behalf.

Providers and suppliers may:

• Submit additional information with the reconsideration that may have a bearing on the

decision. However, if you have additional information that you would like a Hearing Officer

to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to

consider during a hearing, you must submit that information with your request for

reconsideration. This is your only opportunity to submit information during the

administrative appeals process unless an ALJ allows additional information to be submitted.

• Include an email address if you want to receive correspondence regarding your appeal via

email.

If a reconsideration is not requested, CMS deems this a waiver of all rights to further

administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part

498.

The reconsideration request should be sent to:

(Insert correct address based on whether the MAC or CMS is responsible for handling the

reconsideration.

[Name of MAC] [Centers for Medicare & Medicaid Services]

[Address] or [Center for Program Integrity]

[City], ST [Zip] [Provider Enrollment & Oversight Group]

[ATTN: Division of Provider Enrollment Appeals]

[7500 Security Blvd.]

[Mailstop: AR-19-51]

[Baltimore, MD 21244-1850]

Or emailed to:

[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov]

For questions concerning this letter, contact [Insert Contractor] at [contact information].

Sincerely,

[Name]

[Title]

[Company]

C. Approval – Reactivation (DME)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City, State, Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier],

[Insert Contractor] approved your reactivation application.

Medicare Enrollment Information

Your PTAN is the authentication element for all inquiries to customer service representatives

(CSRs), written inquiry units, and the interactive voice response (IVR) system.

To file claims electronically, please contact the Common Electronic Data Exchange (CEDI)

Contractor at www.ngscedi.com or (866) 311-9184.

Subscribe to receive timely listserv messages regarding Medicare billing policies at:

• Jurisdiction A – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme

• Jurisdiction B – CGS, www.cgsmedicare.com

• Jurisdiction C – CGS, www.cgsmedicare.com

• Jurisdiction D – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme

Supplier Legal Business Name (LBN)

Doing Business As (DBA)

Physical Address Location

Supplier Type

National Provider Identifier (NPI)

Provider Transaction Access Number (PTAN)

PTAN Effective Date

Participation Status

Enroll, make changes or view your existing enrollment information by logging into PECOS at

https://pecos.cms.hhs.gov..

Submit updates and changes to your enrollment information within the timeframes specified

at 42 CFR §424.516. For more information on the reporting requirements, go to Medicare

Learning Network Article SE1617.

Find additional Medicare program information, including billing, fee schedules, and Medicare

policies and regulations at [insert contractor’s web address] or https://www.cms.gov.

Right to Submit a Reconsideration Request:

You may request a reconsideration of this determination. This is an independent review

conducted by a person not involved in the initial determination. (Optional Coversheet sentence

[To facilitate the processing of your reconsideration request, please utilize and include the

[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.])

Reconsideration requests must:

• Be received in writing within 65 calendar days of the date of this letter and mailed or emailed

to the address below.

• State the issues or findings of fact with which you disagree and the reasons for

disagreement.

• Be signed by the provider or supplier, an authorized or delegated official that has been

reported within your Medicare enrollment record, or an authorized representative.

o If the authorized representative is an attorney, the attorney’s statement that the attorney

has the authority to represent the provider or supplier is sufficient to accept this

individual as the representative.

o If the authorized representative is not an attorney, the individual provider, supplier, or

authorized or delegated official must file written notice of the appointment of a

representative with the submission of the reconsideration request.

o Authorized or delegated officials for groups cannot sign and submit a reconsideration

request on behalf of a reassigned provider/supplier without the provider/supplier

submitting a signed statement authorizing that individual from the group to act on the

reassigned provider’s/supplier’s behalf.

Providers and suppliers may:

• Submit additional information with the reconsideration that may have a bearing on the

decision. However, if you have additional information that you would like a Hearing Officer

to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to

consider during a hearing, you must submit that information with your request for

reconsideration. This is your only opportunity to submit information during the

administrative appeals process unless an ALJ allows additional information to be submitted.

• Include an email address if you want to receive correspondence regarding your appeal via

email.

If a reconsideration is not requested, CMS deems this a waiver of all rights to further

administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part

498.

The reconsideration request should be sent to:

(Insert correct address based on whether the MAC or CMS is responsible for handling the

reconsideration.

[Name of MAC] [Centers for Medicare & Medicaid Services]

[Address] or [Center for Program Integrity]

[City], ST [Zip] [Provider Enrollment & Oversight Group]

[ATTN: Division of Provider Enrollment Appeals]

[7500 Security Blvd.]

[Mailstop: AR-19-51]

[Baltimore, MD 21244-1850]

Or emailed to:

[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov]

For questions concerning this letter, contact [Insert Contractor] at [contact information].

Sincerely,

[Name]

[Title]

[Company]

D. Approval – Revalidation (DME)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City, State, Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier],

[Insert Contractor] approved your revalidation application.

Medicare Enrollment Information

Supplier Legal Business Name (LBN)

Doing Business As (DBA)

Physical Address Location

Supplier Type

National Provider Identifier (NPI)

Provider Transaction Access Number (PTAN)

PTAN Effective Date

Changed Information Include detailed changes or section

titles, as applicable.

Your PTAN is the authentication element for all inquiries to customer service representatives

(CSRs), written inquiry units, and the interactive voice response (IVR) system.

To file claims electronically, please contact the Common Electronic Data Exchange (CEDI)

Contractor at www.ngscedi.com or (866) 311-9184.

Subscribe to receive timely listserv messages regarding Medicare billing policies at:

• Jurisdiction A – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jadme

• Jurisdiction B – CGS, www.cgsmedicare.com

• Jurisdiction C – CGS, www.cgsmedicare.com

• Jurisdiction D – Noridian Healthcare Solutions, med.noridianmedicare.com/web/jddme

Enroll, make changes or view your existing enrollment information by logging into PECOS at

https://pecos.cms.hhs.gov.

Submit updates and changes to your enrollment information within the timeframes specified

at 42 CFR §424.516. For more information on the reporting requirements, go to Medicare

Learning Network Article SE1617.

Find additional Medicare program information, including billing, fee schedules, and Medicare

policies and regulations at [insert contractor’s web address] or https://www.cms.gov.

Right to Submit a Reconsideration Request:

You may request a reconsideration of this determination. This is an independent review

conducted by a person not involved in the initial determination. (Optional Coversheet sentence

[To facilitate the processing of your reconsideration request, please utilize and include the

[attached] coversheet [also found at [[insert web address for coversheet]] with your submission.])

Reconsideration requests must:

• Be received in writing within 65 calendar days of the date of this letter and mailed or emailed

to the address below.

• State the issues or findings of fact with which you disagree and the reasons for

disagreement.

• Be signed by the provider or supplier, an authorized or delegated official that has been

reported within your Medicare enrollment record, or an authorized representative.

o If the authorized representative is an attorney, the attorney’s statement that the attorney

has the authority to represent the provider or supplier is sufficient to accept this

individual as the representative.

o If the authorized representative is not an attorney, the individual provider, supplier, or

authorized or delegated official must file written notice of the appointment of a

representative with the submission of the reconsideration request.

o Authorized or delegated officials for groups cannot sign and submit a reconsideration

request on behalf of a reassigned provider/supplier without the provider/supplier

submitting a signed statement authorizing that individual from the group to act on the

reassigned provider’s/supplier’s behalf.

Providers and suppliers may:

• Submit additional information with the reconsideration that may have a bearing on the

decision. However, if you have additional information that you would like a Hearing Officer

to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to

consider during a hearing, you must submit that information with your request for

reconsideration. This is your only opportunity to submit information during the

administrative appeals process unless an ALJ allows additional information to be submitted.

• Include an email address if you want to receive correspondence regarding your appeal via

email.

If a reconsideration is not requested, CMS deems this a waiver of all rights to further

administrative review. More information regarding appeal rights can be found at 42 C.F.R. Part

498.

The reconsideration request should be sent to:

(Insert correct address based on whether the MAC or CMS is responsible for handling the

reconsideration.

[Name of MAC] [Centers for Medicare & Medicaid Services]

[Address] or [Center for Program Integrity]

[City], ST [Zip] [Provider Enrollment & Oversight Group]

[ATTN: Division of Provider Enrollment Appeals]

[7500 Security Blvd.]

[Mailstop: AR-19-51]

[Baltimore, MD 21244-1850]

Or emailed to:

[Insert MAC email address] or [ProviderEnrollmentAppeals@cms.hhs.gov]

For questions concerning this letter, contact [Insert Contractor] at [contact information].

Sincerely,

[Name]

[Title]

[Company]

E. Approval – Voluntary Termination (DME)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City, State, Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier],

[Insert Contractor] completed your application to voluntarily disenroll from the Medicare

program.

Medicare Enrollment Information

Supplier Legal Business Name (LBN)

Doing Business As (DBA)

Physical Address Location

Supplier Type

National Provider Identifier (NPI)

Provider Transaction Access Number (PTAN)

Effective Date of Termination and Deactivation

Medicare will not reimburse you for any claims with dates of service on or after your effective

date of termination.

With this voluntary termination, your billing privileges are also being deactivated effective on

the aforementioned date of the termination pursuant to 42 C.F.R. § 424.540(a)(7).

REBUTTAL RIGHTS:

If you believe that this deactivation determination is not correct, you may rebut the deactivation

as indicated in 42 C.F.R. § 424.545(b). The rebuttal must be received by this office in writing

within 15 calendar days of the date of this letter. The rebuttal must state the issues or findings of

fact with which you disagree and the reasons for disagreement. You may submit additional

information with the rebuttal that you believe may have a bearing on the decision. You must

submit all information that you would like to be considered in conjunction with the rebuttal. This

includes any application(s) to update your enrollment, if necessary. You may only submit one

rebuttal in response to this deactivation of your Medicare enrollment.

The rebuttal must be signed and dated by the individual provider/supplier, the authorized or

delegated official, or a legal representative. Please be advised that authorized or delegated

officials for groups cannot sign and submit a rebuttal on behalf of a reassigned provider/supplier

without the provider/supplier submitting a signed statement authorizing that individual from the

group to act on the reassigned provider’s/supplier’s behalf.

If the provider/supplier wishes to appoint a legal representative that is not an attorney to sign the

rebuttal, the provider/supplier must include with the rebuttal a written notice authorizing the

legal representative to act on the provider/supplier’s behalf. The notice should be signed by the

provider/supplier.

If the provider/supplier has an attorney sign the rebuttal, the rebuttal must include a statement

from the attorney that the attorney has the authority to represent the provider/supplier.

If you wish to receive communication regarding your rebuttal via email, please include a valid

email address in your rebuttal submission.

The rebuttal should be sent to the following:

[Contractor Rebuttal Receipt Address]

[Contractor Rebuttal Receipt Email Address]

[Contractor Rebuttal Receipt Fax Number]

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

[x:00 AM/PM ET/CT/MT/PT] and [x:00 AM/PM ET/CT/MT/PT].

Sincerely,

[Name]

[Title]

[Company]