Additional Appeal Levels
A. Administrative Law Judge (ALJ)
Hearing CMS, a Medicare contractor, or a supplier dissatisfied with a reconsidered determination is entitled to a hearing before an ALJ.
The ALJ has delegated authority from the Secretary of the Department of Health and Human Services (DHHS) to exercise all duties, functions, and powers relating to holding hearings and rendering decisions.
Such an appeal must be filed, in writing, within 60 days from receipt of the reconsideration decision.
ALJ requests should be sent to:
Department of Health and Human Services
Departmental Appeals Board (DAB) Civil Remedies Division,
Mail Stop 6132 330
Independence Avenue,
S.W. Cohen Bldg,
Room G-644 Washington,
D.C. 20201
ATTN: CMS Enrollment Appeal (ALJ requests can also be submitted electronically at https://dab.efile.hhs.gov/.) Failure to timely request an ALJ hearing is deemed a waiver of all rights to further administrative review.
Upon receipt of a request for an ALJ hearing, an ALJ at the Departmental Appeals Board (DAB) will issue a letter by certified mail to the supplier, CMS and the Regional Office of General Counsel (OGC) acknowledging receipt of an appeals request and detailing a scheduled pre-hearing conference.
The OGC will assign an attorney to represent CMS during the appeals process; he/she will also serve as the DAB point of contact. Neither CMS nor the Medicare contractor are required to participate in the prehearing conference but should coordinate among themselves and the OGC attorney prior to the pre-hearing to discuss any issues.
The Medicare contractor shall work with and provide the OGC attorney with all necessary documentation. This includes compiling and sending all relevant case material to the OGC attorney upon the latter’s request within 5 calendar days of said request.
Any settlement proposals, as a result of the pre-hearing conference, will be addressed with CMS.
B. Departmental Appeals Board (DAB)
Hearing CMS, a Medicare contractor, or a supplier dissatisfied with the ALJ hearing decision may request a Board review by the DAB. Such a request must be filed within 60 days after the date of receipt of the ALJ’s decision. Failure to timely request a DAB review is deemed to be a waiver of all rights to further administrative review.
The DAB will use the information in the case file established at the reconsideration level and any additional evidence introduced at the ALJ hearing to make its determination.
The DAB may admit additional evidence into the record if the DAB considers it relevant and material to an issue before it. Before such evidence is admitted, notice is mailed to the parties stating that evidence will be received regarding specified issues.
The parties are given a reasonable time to comment and to present other evidence pertinent to the specified issues. If additional information is presented orally to the DAB, a transcript will be prepared and made available to any party upon request.
C. Judicial Review
A supplier dissatisfied with a DAB decision may seek judicial review by timely filing a civil action in a United States District Court. Such a request shall be filed within 60 days from receipt of the notice of the DAB’s decision.
Appeals Involving Certified Providers and Certified Suppliers
Sections 15.25.2.1 through 15.25.2.3 below apply to:
• Providers and suppliers completing the Form CMS-855A
• Ambulatory surgical centers
• Portable x-ray suppliers
• Also, section 15.25.2.2 applies to reconsiderations of revocations based wholly or partially on §424.535(a)(8), regardless of provider or supplier type.
Corrective Action Plans (CAPs)
A. Submission of CAPs
The CAP process gives a provider or supplier (hereinafter collectively referred to as “providers”) an opportunity to correct the deficiencies (if possible) that resulted in the denial of its application or the revocation of its billing privileges.
The CAP must:
(1) Contain, at a minimum, verifiable evidence that the provider is in compliance with Medicare requirements;
(2) Be submitted within 30 days from the date of the denial or revocation notice;
(3) Be submitted in the form of a letter that is signed and dated by the individual supplier, the authorized or delegated official, or a legal representative.
(4) For revocations, be based on §424.535(a)(1).
Consistent with §405.809, CAPs for revocations based on grounds other than §424.535(a)(1) cannot be accepted. (For revocations based on multiple grounds of which one is §424.535(a)(1), the CAP may be accepted with respect to (a)(1) but not with respect to the other grounds.)
CMS’ Provider Enrollment & Oversight Group (PEOG), which processes all CAPs, will notify the provider if a CAP cannot be accepted.
CAP requests must be sent to the following address:
Centers for Medicare & Medicaid Services Center for Program Integrity Provider Enrollment & Oversight Group 7500 Security Boulevard Mailstop AR 18-50 Baltimore, MD 21244-1850
If the contractor inadvertently receives a CAP request, it shall immediately forward it to PEOG at this address or, if possible, to the following PEOG mailbox: providerenrollmentappeals@cms.hhs.gov . Also:
• PEOG may make a good cause determination so as to accept any AP that has been submitted beyond the 30-day filing period.
• The provider’s contact person (as listed in section 13 of the Form CMS-855) does not qualify as a “legal representative” for purposes of signing a reconsideration request.
B. Processing and Approval of CAPs
PEOG will process a CAP within 60 days. During this period, PEOG will not toll the filing requirements associated with a reconsideration request. If PEOG approves a CAP, it will: (1) notify the contractor to rescind the denial or revocation and permit or restore enrollment (as applicable), and (2) notify the provider thereof via letter. If applicable, PEOG will also notify the contractor of the effective date.
If PEOG denies a CAP, it will notify the provider via letter (on which the contractor will be copied) of the denial and associated appeal rights.
Reconsideration Requests – Certified Providers and Certified Suppliers
This section 15.25.2.2 also applies to reconsiderations of revocations based wholly or partially on §424.535(a)(8), regardless of provider or supplier type.
A. Timeframe for Submission
A provider that wishes to request a reconsideration must submit its request, in writing, to CMS’ Provider Enrollment & Oversight Group (PEOG) within 60 days from the supplier’s receipt of the notice of denial or revocation to be considered timely filed. Per 42 CFR §498.22(b)(3), the date of receipt is presumed to be 5 days after the date on the notice unless there is a showing that it was, in fact, received earlier or later.
The mailing address is:
Centers for Medicare & Medicaid Services Center for Program Integrity Provider Enrollment & Oversight
Group 7500
Security Boulevard Mailstop AR-18-50 Baltimore,
MD 21244-1850
PEOG will extend the filing period an additional 5 days to allow for mail time. A reconsideration request submitted on the 65 thday that falls on a weekend or holiday will still be considered timely filed.
The date on which PEOG receives the request is considered to be the date of filing. Failure to timely request a reconsideration is deemed a waiver of all rights to further administrative review.
However, if a request for reconsideration is filed late, PEOG will make a finding of good cause before taking any other action on the appeal. The time limit may be extended if good cause for late filing is shown.
Good cause may be found when the record clearly shows or the party alleges and the record does not negate that the delay in filing was due to one of the following:
• Unusual or unavoidable circumstances, the nature of which demonstrate that the individual could not reasonably be expected to have been aware of the need to file timely; or • Destruction by fire, or other damage, of the individual’s records when the destruction was responsible for the delay in filing.
B. Signatures
A reconsideration request must be signed by an authorized official, delegated official, or legal representative of the provider. The provider’s contact person (as listed in section 13 of the Form CMS-855) does not qualify as a “legal representative” for purposes of signing a reconsideration request.
C. Receipt of Reconsideration Request
Upon receipt of a reconsideration request, PEOG will send a letter to the provider to acknowledge receipt of the request. In its acknowledgment letter, PEOG will advise the provider that the reconsideration will be conducted and a determination issued within 90 days from the date of the request. PEOG will include a copy of the acknowledgment letter in the reconsideration file. If the contractor inadvertently receives a reconsideration request from a certified provider or certified supplier, it shall immediately forward it to PEOG at this address or, if possible, to the following PEOG mailbox: providerenrollmentappeals@cms.hhs.gov .
D. Reconsideration Determination
As already stated, if a timely request for a reconsideration is made, PEOG will consider the request and issue a determination within 90 days of the request. The HO must determine whether the denial or revocation is warranted based on all of the evidence presented.
This includes:
• The initial determination itself,
• The findings on which the initial determination was based,
• The evidence considered in making the initial determination, and
• Any other written evidence submitted under § 498.24(a), taking into account facts relating to the status of the provider or supplier subsequent to the initial determination.
If the appealing party has additional information that it would like a hearing officer to consider during the reconsideration or, if necessary, an administrative law judge to consider during a hearing, the party must submit that information with its request for reconsideration.
This is the party’s only opportunity to submit information during the administrative appeals process; the party will not have another opportunity to do so unless an administrative law judge specifically allows the party to do so under 42 CFR §498.56(e). The contractor may not introduce new denial or revocation reasons or change a denial or revocation reason listed in the initial determination during the reconsideration process.
E. Issuance of Reconsideration Decision
PEOG will issue a written decision within 90 days of the date of the request. It will: (1) forward the decision to the Medicare contractor via e-mail, fax, or mail, and (2) mail the decision to the provider or the individual who signed the reconsideration request.
The reconsideration letter will include:
• The re-stated facts and findings, including the regulatory basis for the action as determined by the contractor in its initial determination;
• A summary of the documentation that the provider furnished;
• A clear explanation of why PEOG is upholding or overturning the denial or revocation action in sufficient detail for the provider to understand PEOG’s decision and, if applicable, the nature of the provider’s deficiencies;
• If applicable, the regulatory basis to support each reason for the denial or revocation;
• If applicable, an explanation of how the provider does not meet the enrollment criteria or requirements;
• Further appeal rights, procedures for requesting an administrative law judge (ALJ) hearing, and the address to which the written appeal must be mailed or e-mailed; and
• Information that the provider must include with its appeal (name/legal business name; supplier number (if applicable); tax identification number/employer identification number (TIN/EIN); and a copy of the reconsideration decision). If PEOG approves a CAP, it will: (1) notify the contractor to rescind the denial or revocation and issue or restore billing privileges (as applicable), and (2) notify the provider thereof via letter. If applicable, PEOG will also notify the contractor of the effective date.
F. Withdrawal of Reconsideration Request
The provider or the individual who signed the reconsideration request may withdraw its request at any time prior to the mailing of the reconsideration decision. The withdrawal request must be in writing, signed, and filed with PEOG at the address in (A) above.
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