Optional_2023 Board Resources

(i) The provider or supplier is not in compliance with the enrollment requirements applicable for its provider or supplier type; 109 (ii) The provider or supplier, or any responsible party or other health care personnel of the provider or supplier is excluded from Medicare, Medicaid, and any other federal health care program or is debarred, suspended, or otherwise excluded from participating in any other federal program or activity; (iii) The provider, supplier, or any owner or managing employee of the provider or supplier was, within the preceding 10 years, convicted of certain felonies; 110 (iv) The provider or supplier certified as “true” misleading or false information on its Medicare enrollment application; (v) Upon on-site review or other reliable evidence, the provider or supplier is either no longer operational to furnish Medicare-covered items or services or otherwise fails to satisfy any Medicare enrollment requirement; (vi) An institutional provider does not submit an application fee or hardship exception request with its Medicare revalidation application or for any reason CMS is unable to deposit the application fee; (vii) The provider or supplier knowingly sells to or allows another individual or entity to use its billing number; (viii) The provider or supplier submits a claim or claims for services that could not have been furnished to a specific individual on the date of service or CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements; (ix) The provider or supplier did not comply with certain reporting or documentation requirements; (x) A home health agency (HHA) cannot furnish supporting documentation verifying that the HHA meets the initial reserve operating funds requirement; (xi) Medicaid billing privileges are terminated or revoked by a state Medicaid Agency and the provider or supplier has exhausted all applicable appeal rights; (xii) The provider’s DEA certificate has been suspended or revoked, or the provider’s ability to prescribe drugs has been otherwise suspended or revoked by the applicable state licensing body; (xiii) CMS determines that the physician or eligible professional has a pattern or practice of improperly prescribing Part D drugs. When determining whether a provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements, CMS considers: (i) The percentage of submitted claims that were denied; (ii) The reason(s) for the claim denials; 109 In this circumstance, the provider or supplier can correct the specific deficiencies that resulted in its revocation through a Corrective Action Plan (CAP). The CAP must be submitted within 30 days from the date of the revocation notice. If the CAP is approved by CMS, the provider’s or supplier’s Medicare billing privileges will be restored as of the date of full compliance. If the CAP is denied by CMS, the provider can still appeal. 110 If the revocation was due to adverse activity (sanction, exclusion, or felony) against a responsible party or other personnel of the provider or supplier, the revocation may be reversed if the provider or supplier terminates and submits proof of termination within 30 days of the revocation notification.