CMS Pub. 100-08, ch. 10, § 10.7.5.1.1

This section 10.7.5.1.1 contains additional letters that contractors shall use in certain special

situations involving certified providers and suppliers. They take precedence over all other letters

in this chapter potentially pertaining to the situations described in this section

A. Denials Based on Survey Failure for Transitioned Certified Providers/suppliers

(This letter does not apply to non-transitioned certified providers/suppliers.)

[Month, Day, Year]

[Provider/Supplier Name]

[Address]

[City] ST [Zip]

Reference # (Application Tracking Number)

Dear [Provider/Supplier]:

We regret to inform you that (Provider/Supplier] does not meet the requirements for participation

in the Medicare program (Title XVIII of the Social Security Act).

In order to participate in the Health Insurance for the Aged and Disabled Program, a [list the

provider/supplier type] must be in compliance with all applicable Conditions of [Participation or

Coverage, as applicable] established by the Secretary of Health and Human Services. Based on

the [list date survey occurred] survey conducted by [list the state agency or accrediting

organization name], CMS has determined that your facility does not qualify. The deficiencies

that the [list the state agency or accrediting organization name] found are listed on the Survey

Report. Your facility is not in compliance with the following Conditions of [Participation or

Coverage]:

§ [List regulatory cite (e.g., 42 CFR § 418.56) and the specific provision in question (e.g.,:

Interdisciplinary Group, Care Planning, and Coordination of Services]

You may take steps to correct the deficiencies and reapply to establish eligibility. However,

current survey funding levels (as appropriated by Congress) may not allow for a resurvey. CMS’

priority for use of the limited funds available are to ensure the health and safety of Medicare

beneficiaries at currently participating facilities. Contact [list the state survey agency or

accrediting organization that performed the initial survey] for the status of initial surveys of non-participating facilities.

Please note that you may submit no more than two reapplications for certification in connection

with one enrollment application, and no more than six months may elapse between the date of

the first survey denial notification and the CMS Survey & Certification Group’s receipt of the

second reapplication for certification. Applicants who reapply for certification must undergo and

pass a subsequent survey. (Note that a reapplication for certification is different from the

submission of a [Form CMS-855A or Form CMS-855B, as applicable to the provider/supplier

type] Medicare enrollment application. At this time, you need not submit a [Form CMS-855A or

Form CMS-855B, as applicable] to request another survey per the previous paragraph.)

If you believe that this decision is not correct, you may request that this decision be reconsidered.

The request must be submitted in writing to [list applicable SOG Location] within 60 days of the

date you receive this notice. You may submit with your request any additional information which

you feel may have a bearing on this decision. If you have any questions, please contact [list

appropriate SOG Location contact person] at xxxxxx@cms.hhs.gov.

Sincerely,

[Name]

[Title]

[Company]

CC: State Agency [and AO, if applicable]