Medicare enrollment is the essential first step before physicians, providers and suppliers can bill Medicare. Enrollment applications are processed by the Medicare claims processing contractors for the provider jurisdiction.
Medicare enrollment denials can bring financial disaster to health care providers seeking to treat Medicare beneficiaries. Recognizing this potential impact, Congress enacted the enrollment appeals provisions of the Medicare Prescription Drug, Modernization and Improvement Act of 2003.
Any provider whose Medicare billing privileges are revoked or whose enrollment application is denied has a right to appeal the determination. Aggrieved parties must exhaust all administrative processes before filing a case in court.
Instructions
1. Review any denial or revocation letter sent from the Medicare contractor that made the adverse determination.
The denial letter contains the reasons for rejecting the provider's enrollment application, and provides information on the appeal process. Revocation letters are sent 30 days before the effective date of the revocation and include the basis for the decision.
2. Request a reconsideration from the Medicare contractor. This was formerly referred to as a contractor hearing.
You must sign the reconsideration request and ensure that the contractor receives it within 60 days of the postmark date on the denial or revocation notice. The denial letter will contain information on where to file the reconsideration request and your right to present new evidence.
Failure to timely request a reconsideration is a waiver of any further rights to appeal.
3. File a request for an administrative law judge (ALJ) hearing if the reconsideration request is not successful. This must be done in writing, within 60 days of receiving the reconsideration determination. The request should be sent to:
Department of Health and Human Services Departmental Appeals Board (DAB)
Civil Remedies Division
Mail Stop 6132
Cohen Bldg, Room G-644
220 Independence Avenue, S.W.
Washington, D.C. 20201
ATTN: CMS Enrollment Appeal
The DAB will send a certified letter notifying you of the ALJ assigned to the case, and providing the date and time for the prehearing conference.
If you do not file a request for an ALJ hearing on time, you waive all rights to further appeal.
4. Request a hearing before the Departmental Appeals Board (DAB) within 60 days of receiving an unfavorable ALJ decision. Failure to timely file a request for DAB review is a waiver of all rights to further review.
5. File a civil action in federal district court within 60 days of receiving notice of the DAB's unfavorable decision. It may be convenient to file suit in the federal court serving the jurisdiction in which your practice is located.
