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Corporate

Corrective Action Plan (CAP) and Reconsideration Process

What is a CAP:

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).

What must be included with CAP:

When submitting a CAP, it must:

  1. Contain verifiable evidence that the provider/supplier is in compliance with Medicare requirements;
  2. Be submitted within 35 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 provider/supplier, the authorized or delegated official, or a legal representative.
  4. If a legal representative is an attorney, the CAP must also contain a statement that the attorney has the authority to act on behalf of the provider/supplier. If the legal representative is not an attorney, the CAP must contain written notice of the appointment of the non-attorney as legal representative signed by the provider, supplier, or authorized/delegated official.
  5. CAP / Reconsideration form available herePDF.

MAC process of CAP:

A decision will be issued within 60 days of receipt of the CAP.

What is a Reconsideration:

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.

What must be included with Reconsideration:

When submitting a reconsideration request, it must:

  1. State the issues, or the findings of fact with which you disagree, and the reasons for disagreement.
  2. Be submitted within 65 days from the date of the initial determination;
  3. Be submitted in the form of a letter that is signed and dated by the individual provider/supplier, the authorized or delegated official, or a legal representative.
  4. If a legal representative is an attorney, the reconsideration request must also contain a statement that the attorney has the authority to act on behalf of the provider/supplier. If the legal representative is not an attorney, the reconsideration request must contain written notice of the appointment of the non-attorney as legal representative signed by the provider, supplier, or authorized/delegated official.
  5. CAP / Reconsideration form available herePDF.

MAC process of Reconsideration:

A decision will be issued within 90 days of receipt of the reconsideration request.

CAP or Reconsideration request should be sent to one of the following:

Mail: Centers for Medicare & Medicaid Services
Provider Enrollment & Oversight Group
7500 Security Blvd.
Mailstop: AR-18-50
Baltimore, MD 21244-1850

or

E-mail: ProviderEnrollmentAppeals@cms.hhs.gov

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