Office of Clinical Standards and Quality/ Survey & Certification Group
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1 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7000 Security Boulevard, Mail Stop Baltimore, Maryland Office of Clinical Standards and Quality/ Survey & Certification Group DATE: December 23, 2011 Ref: S&C: ALL TO: FROM: SUBJECT: State Survey Agency Directors Director Survey and Certification Group Survey and Certification Responsibilities Related to Provider Enrollment Revocations Memorandum Summary Termination of Provider Agreement Upon Revocation: Revocation of a provider s billing privileges in the Medicare program automatically results in termination of the associated provider agreement, according to regulations at 42 CFR (b), for all provider types. Centers for Medicare & Medicaid Services (CMS) Regional Office Role: This memo outlines the responsibilities of the Regional Office (RO) when the Medicare Administrative Contractor/Fiscal Intermediary (MAC/FI) issues a notice of revocation to a provider. Background: Regulations at (b) state that when a provider's or supplier's billing privileges are revoked, the provider agreement in effect at the time of revocation is terminated, effective with the date of revocation. Process: The MAC/FI will send a copy of the revocation letter to the RO Division of Survey & Certification (DSC) corporate mailbox and stipulate the effective date of revocation. This letter will include all appeal rights available to the provider pursuant to the revocation, per (a) (ii), including the opportunity for the provider to submit a request for reconsideration to the Provider Enrollment Operations Group (PEOG) in Baltimore. Provider questions received by the State Survey Agency (SA) or CMS RO concerning the notification of revocation or the associated appeal processes should be directed to the applicable MAC/FI. The PEOG will notify the applicable RO and the Survey and Certification Group of all reversals as a result of reconsideration. The RO will hold termination action for 150 days to enable the provider enrollment reconsideration process to be completed. If, by the end of that period, the RO has not received notification that the revocation was reversed through the reconsideration process, the RO will verify with the MAC/FI that the revocation is still effective and begin termination procedures. Please see attached list of MAC/FI contacts.
2 Page 2 State Survey Agency Directors The RO will follow the routine procedures for the termination of the provider agreement as directed in the State Operations Manual (SOM) and at The notification of the termination will include language that the provider agreement is being terminated pursuant to the revocation of the provider s enrollment per and retroactive to the date of revocation. The letter will provide usual appeal opportunities. The RO will provide concurrent notice to the public, as required by , informing that in 15 days the Medicare agreement for this facility will be terminated retroactive to the date of revocation. The RO will send a tie-out notice (Form CMS-2007) to the MAC/FI indicating an involuntarily termination and noting the termination date as the revocation date. The RO will terminate the provider in the Automated Survey Processing Environment (ASPEN) with a termination code of 6 failure to meet agreement. The RO will notify the State on all revocations and pending terminations. However, until termination, which will not occur until 150 days after the notice of revocation, the SA must proceed with all scheduled and complaint surveys. Prior to the SA performing a survey the RO/SA will discuss the case to determine the status of the revocation process. Effective Date: This guidance is effective immediately. Please ensure that all appropriate staff is fully informed within 30 days of the date of this memorandum. Training: This policy should be shared with all survey and certification staff, their managers and the State/RO training coordinator. Attachments: (a) Provider Notice (b) Public Notice (c) MAC/FI Contacts /s/ Thomas E. Hamilton cc: Survey and Certification Regional Office Management
3 Survey and Certification Issues Related to Provider Enrollment Revocations. Model Template for 15 day provider notice with reference to (a)(ii) and Sec Termination by CMS. [Date] Re: CMS Certification Number (CCN): XX-XXXX Provider Name Address City, State ZIP Dear [Administrator]: The Centers for Medicare & Medicaid Services (CMS) has been notified by [Name of MAC] that the Medicare billing privileges for [Name of provider] have been revoked, pursuant to 42 CFR (a). This action also terminates your corresponding Medicare provider agreement per Your provider agreement is terminated retroactive to the date of revocation of your Medicare enrollment [date]. We will publish a public notice in the [name of paper]. If you believe this action is not correct, please refer to the letter which was sent to you on [insert date] from [Name of MAC] notifying you of the revocation of your Medicare enrollment. This letter included your rights to appeal. If you have any questions, please contact me at XXX.XXX.XXXX or [first, last]@cms.hhs.gov. Sincerely, XXXXXXXXXXX Manager [Name of Branch] cc: [Name of MAC] Provider Enrollment Operations Group, CMS Baltimore [Name of State survey agency]
![that the Medicare billing privileges for [Name of provider] have been revoked, pursuant to 42 CFR 424.545(a). This action also terminates your corresponding Medicare provider agreement per 489.53.](/docs-images/42/9958363/images/page_3.jpg "Your provider agreement is terminated retroactive to the date of revocation of your Medicare enrollment [date]. We will publish a public notice in the [name of paper].")
4 Model Template for Public Notice Revocation MEDICARE NOTICE TO THE PUBLIC Notice is hereby given that on (15 days from the notice) the agreement between (Name, City and State) and the Secretary of Health and Human Services, as a (provider Type) in the Medicare program will be terminated retroactive to (date of the revocation) pursuant to revocation of billing privileges based on 42CFR The Centers for Medicare & Medicaid Services has determined that (name of provider) is no longer in compliance with the requirements for enrollment and participation in the Medicare program (Title XVIII of the Social Security Act). The Medicare program will not make payment for covered services furnished to patients at (name of provider) on or after (Date of revocation). Name ARA Certification & Enforcement Branch
5 Contractor Name/Number DPSE Contractor Liaison Contract Manager Name, Phone #, and Internet address) Back up Contact Manager Name, Phone #, and Internet address) J 13 NGS (13101, 13201) Dave.Neiheisel@wellpoint.com Theodore Kavanaugh (315) Theodore.Kavanaugh@wellpoint.com J13 NGS (13102, 13202, 13282, 13292) Jill Parker (717) Jill.Parker@wellpoint.com Tamara Cooksey (717) Tamara.Cooksey@wellpoint.com NGS.Anthem (130, 131, 160, 332) Dave.Neiheisel@wellpoint.com Sandra Brown (513) Sandra.Brown@wellpoint.com NGS/United Government Services (450, 452, 453) Dave.Neiheisel@wellpoint.com.com Chris Troesch, WI Christine.Troesch@wellpoint.com NGS/AdminaStar (456) Dave.Neiheisel@hem.com Sandra Brown (513) Sandra.Brown@anthem.com NGS/AdminaStar (630, 660) Kim Dooley (317) Kim.Dooley@wellpoint.com Kyra Blair, IN & KY (317) Kyra.Blair@wellpoint.com Highmark Medicare Services (J12) Nannette Hardouin Debra Jones (717) debra.jones@highmarkmedicareservices.com Cindy White (717) cindy.white@highmarkmedicareservices.com Cahaba (Mississippi) Legacy Melanie Widman Melanie.widman@cahabagba.com Vince Cook (205) Vince.Cook@cahabagba.com Kay Dodd (205) Kay.Dodd@cahabagba.com Cahaba (J10) Melanie Widman Melanie.widman@cahabagba.com Vince Cook (205) Vince.Cook@cahabagba.com Kay Dodd (205) Kay.Dodd@cahabagba.com Cahaba (J10) Larry Parton lparton@cahabagba.com RHHI (J15) Nannette Hardouin Pam Anderson pamela.anderson@rgbagov.com TrailBlazer Health (J4) Forence Ng (469) Florence.Ng@trailblazerhealth.com Lou Ann Otts (469) Lou.Otts@trailblazerhealth.com SC Attachment C_MAC_FI Contacts updated_ xls
6 TrailBlazer Health (J4) Ken Kerns (469) Sheryl Manis Leslie Bewley Jackie Fox Virginia Rhodes CGS (J15) Part B Idaho/N. Carolina & Tennessee Nannette Hardouin Shirley Roberts (615) Shirley.Roberts@CIGNA.com Karen Hughes (615) Karen.Hughes@cigna.com Judy Martin (615) Judy.Martin@cigna.com Phyllis White (615) Phyllis.White@cigna.com Palmetto GBA (J11) Connor Beck Teresa Newton (803) Teresa.Newton@palmettogba.com Sandy Boyer (614) Sandy.Boyer@palmettogba.com Wisconsin Physician Services (951, 952, 953, 954, 05102, 05202, & 05402) Cheryl Brown Kim Richmond, Legacy & Mac J Kim Richmond@wpsic.com Richard Jobin, Legacy Richard.Jobin@wpsic.com Jan Warner, Legacy & Mac J Janice.Warner@wpsic.com Angie Mitchell, Legacy & Mac J Angela.Mitchell@wpsic.com Theresa Dahlk, Legacy & Mac J Theresa.Dahlk@wpsic.com Joanne Hall, Legacy Joanne.Hall@wpsic.com Wisconsin Physician Services (52280)(05101, 05201, & 05401) Noridian (J3 and 320 & 322) Noridian (821) Cheryl Brown Nic Chesnut (402) nic.chesnut@wpsic.com Scott Oien (701) scott.oien@noridian.com Scott Oien (701) scott.oien@noridian.com Catherine Hughes (402) Catherine.Hughes@wpsic.com Kim Richmond, WI (608) kim.richmond@wpsic.com Alana Brekken (701) alana brekken@noridian com Alana Brekken (701) alana brekken@noridian com SC Attachment C_MAC_FI Contacts updated_ xls
7 Palmetto GBA (J1) Connor Beck Craig Domanik (904) Cindy Perrone (904) First Coast Service Options (J9) Connor Beck Marian Love ( ) JoAnne Kacena (904) NHIC (J14) Carlene Vitello (781) Deborah Davis (781) Pinnacle (233) David W Couvillon (225) DWCOUVILLON@pinnaclebsi.com Pam Wilson (601) pbwilson@lamsmedicare.com Pinnacle (20/21) David W Couvillon (225) DWCOUVILLON@pinnaclebsi.com Pam Wilson (601) pbwilson@lamsmedicare.com Pinnacle (520, 524, 528) Arkansas, Rhode Island, Louisiana David W Couvillon (225) DWCOUVILLON@pinnaclebsi.com Monica Bates (225) mlbates@pinnaclebsi.com National Supplier Clearinghouse Barry Bromberg Nancy Parker Nancy.Parker@palmettoGBA.com Anthony Rogers Anthony.Rogers@palmattogab.com Last updated - 12/14/2011 SC Attachment C_MAC_FI Contacts updated_ xls
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