Last Modified: 3/25/2024
Location: FL, PR, USVI
Business: Part A, Part B
Suppliers may submit a provider enrollment appeal in the form of a corrective action plan (CAP) or reconsideration request for Part B non-certified suppliers to us.
For purposes of this chapter, in accordance with 42 C.F.R. § 498.3, an initial determination includes:
• Denial of enrollment in the Medicare program.
• Revocation of a provider's or supplier's Medicare billing privileges.
• Effective date of participation in the Medicare program.
The CAP is an opportunity for the provider/supplier to correct the deficiencies (if possible) that resulted in the denial or revocation of billing privileges. A CAP may only be submitted for denials under 42 C.F.R. § 424.530(a)(1) or revocation of billing privileges under 42 C.F.R. § 424.535(a)(1).
A reconsideration request is an opportunity for a provider/supplier to furnish evidence that demonstrates that there was an error made at the time of the initial determination affecting participation in the Medicare program.
In situations where you may submit either a CAP or a reconsideration request, we recommend that you submit a CAP as the processing time may be quicker. In addition, if you submit a CAP and a reconsideration request concurrently, we will first process and make a determination on the CAP.
Provider enrollment includes an attachment with certain correspondence so that you may identify a CAP or reconsideration request when you submit. This attachment will typically be included when you have appeal rights for one of the reasons listed above. Some letters do not include this attachment, so it is important that you read the letter carefully to ensure you have appeal rights and to assist you in identifying your request as a CAP or reconsideration.
If your letter provides appeal rights along with this attachment, please do not use the attachment unless you wish to appeal one of the reasons listed above. For example, if there was a typographical error in your letter, this is not considered an appealable reason; therefore, you should not submit a CAP or reconsideration request. For typographical errors, please contact the provider enrollment representative who processed your application or call provider enrollment . Only use the attachment for the reasons listed above. If you submit another type of request with the attachment, it may be delayed.
The processing time for a CAP is 60 calendar days from the date of receipt of the accepted CAP, and the processing time for a reconsideration is 90 calendar days from the date of receipt of the accepted reconsideration request.
Please mail or email the CAP or reconsideration request letter, the initial determination letter, and all supporting documentation to one of the following:
• First Coast Service Options, Inc.
P.O. Box 3409
Mechanicsburg, PA 17055-1849
• Email: FCSOJNPEAppeals@fcso.com
Note: Only use these mailing addresses or email addresses for Part B non-certified suppliers for the reasons listed above. If you submit another type of request to the addresses above, it may be delayed.
Any CAP and/or reconsideration requests received in response to one of the following will be sent to CMS:
• All CAPs and reconsideration requests for certified providers/suppliers (as defined in Sections 10.2.1 and 10.2.2 of CMS' Program Integrity Manual, Chapter 10) and institutional providers/suppliers which have been revoked (as defined in Section 10.4(M)(2)(e)).
• CAPs and reconsideration requests for independent diagnostic testing facilities.
• CAPs and reconsideration requests for Medicare diabetes prevention programs.
• CAPs and reconsideration requests for opioid therapy programs.
• Reconsideration requests for enrollment denials pursuant, in whole or in part, to 42 C.F.R. § 424.530(a)(2), (3), (6), (11), (12), (13), and (14), (15) and (17).
• Reconsideration requests for revocations pursuant, in whole or in part, to 42 C.F.R. § 424.535(a)(2), (3), (4), (7), (8), (10), (12), (13), (14), (15), (17), (18), (19), (20), (21), and (22).
• Requests for reversals of denials pursuant to 42 C.F.R. § 424.530(c) and/or revocations pursuant to 42 C.F.R. § 424.535(e).
• Reconsideration requests for revocations pursuant, in whole or in part, to 42 C.F.R. § 424.535(j).
• Reconsideration requests challenging the addition of years to an existing re-enrollment bar.
• Reconsideration requests challenging whether an individual or entity other than the provider or supplier that is the subject of the second revocation was the actual subject of the first revocation.
• Reconsideration requests challenging an individual or entity being included on the CMS preclusion list as defined in § 422.2 or § 423.100.
• Reconsideration requests regarding opt-out status.
Any CAP and/or reconsideration requests received in response to one of the bullets above should be sent to the mailing address or email address listed below.
Centers for Medicare & Medicaid Services
Center for Program Integrity
Provider Enrollment & Oversight Group
Attn: Division of Provider Enrollment Appeals
7500 Security Blvd.
Mailstop AR-19-51
Baltimore, MD 21244-1850
Upon receipt of a properly submitted CAP or reconsideration request, we will issue an acknowledgment letter within 14 calendar days of the date of receipt.
Note: CAPs must be received within 35 calendar days from the date of the denial or revocation notice. Reconsideration requests must be received within 65 days from the date of the denial, revocation, or an effective date determination.
The CAP and/or reconsideration request must be submitted in the form of a letter that is signed by the individual provider, supplier, the authorized or delegated official, or a properly appointed representative, as defined in 42 C.F.R. § 498.10.
If the representative is an attorney, the attorney must include a statement that he or she has the authority to represent the provider or supplier.
If the representative is not an attorney, the provider or supplier must file written notice of the appointment of a representative with the contractor. This notice of appointment must be signed by the individual provider or supplier, or the authorized or delegated official. The signature does not need to be original and can be electronic.
Authorized or delegated officials for groups cannot sign and submit a CAP and/or reconsideration request on behalf of a reassigned provider/supplier without the provider/supplier submitting a signed statement authorizing that individual from the group to act on his/her behalf.
If you have any questions, please visit our
website or contact our office at:
888-845-8614.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
