CMS created the Preclusion List with three main goals:
- To ensure that problematic prescribers do not receive payment for prescribing Part D drugs
- To reduce burdens on Part D and Medicare Advantage providers while maintaining program integrity
- To replace Medicare Advantage’s enrollment requirements
What is the preclusion list for Medicare Advantage?
Preclusion List What is the Preclusion List? A list of providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. Why was the list created? To replace the Medicare Advantage (MA) and prescriber enrollment requirements.
What is the preclusion list and why is it important?
CMS Preclusion List . Quick Reference Guide NOTE: Part D sponsors and MA plans should not begin requesting access to the Preclusion List until September 1, 2018. ... EIDM is the system that connects you to all the Centers for Medicare & Medicaid Services (CMS) applications with one central user ID. The EIDM user authentication process prevents
What is a Medicare preclusion action?
Preclusion List Frequently Asked Questions (FAQs) General . 1. What is the Preclusion List? The Preclusion List is comprised of any individual or entity that meets the following criteria: • Is currently revoked from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is
When will the CMS preclusion list be published?
Nov 09, 2021 · The Preclusion List names providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. The Preclusion List applies only to Medicare Advantage items and services or Part D drugs for Medicare beneficiaries.
What is the difference between preclusion and exclusion?
The Preclusion List and exclusion file overlap in the sense that excluded providers will be on the preclusion list, but precluded providers who are not excluded will not be on the exclusion file. Therefore, if a plan finds a provider on the OIG exclusion file, the plan is not required to check the Preclusion List.Jan 27, 2020
Where can I find the CMS preclusion list?
You will need an EIDM user ID to access the CMS preclusion List. Go to the CMS Enterprise Portal at https://portal.cms.gov and choose “New User Registration.” > Use the drop-down menu to choose “CMS Preclusion List” as your application.
Who can access the preclusion list?
CMS approved healthcare plansPreclusion List File 23. Who is able to access the Preclusion List? Only CMS approved healthcare plans, with a valid Health Plan ID, can gain access to the Preclusion List.Dec 16, 2020
What is a preclusion letter?
The Preclusion List is a list generated by CMS that contains the names of prescribers, individuals, and or entities that are unable to receive payment for Medicare Advantage (MA) items and service and or Part D drugs prescribed or provided to Medicare beneficiaries.Feb 13, 2019
Is the CMS preclusion list public?
Because the CMS Preclusion List is not publicly available, it can be difficult for organizations to screen against it. Although individuals and entities on the list receive a notification, healthcare organizations and entities also need this information to avoid hiring precluded providers.Nov 9, 2021
What is a CMS exclusion list?
The CMS Preclusion List is a registry of all health care providers, suppliers, and prescribers who are precluded from receiving reimbursement for Part C Medicare Advantage items and services or Part D drugs that are provided or prescribed to Medicare beneficiaries.May 26, 2021
What is a Medicare revocation?
Medicare billing privileges can be revoked for twenty-two enumerated reasons, including non-compliance with Medicare enrollment requirements, felony convictions, and failure to respond to requests for medical records.Mar 1, 2021
What is a MA organization?
MA organization means a public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.
How long does a provider have to reenroll in Medicare?
The re-enrollment bar becomes effective 30 days from the date of issuance of the initial determination letter and lasts a minimum of 1 year, but not greater than 10 years, depending on the severity of the basis for revocation. In addition, CMS may impose a re-enrollment bar of up to 20 years if the provider or supplier is being revoked from Medicare for the second time.
When will the CMS release the preclusion list?
In an effort to provide MA and Part D plans more time to process new providers and reinstatements received on the Preclusion List, CMS will publish the Preclusion List by the 25th of each month or the last Monday of the month, whichever is earlier, for the following month. These changes will be implemented with the Preclusion List published in September 2019 (i.e., CMS will publish the September Preclusion List on August 26th as August 25th falls on a weekend).
Is a beneficiary notice required for a 2018 HPMS guidance memo?
Yes. The beneficiary notice attached to the November 2, 2018 HPMS guidance memo is a sample notice. Plans are not required to use this version for the required beneficiary notice, however, the letters should include the information specified in the sample notice.
Can a beneficiary appeal a preclusion?
No, we do not believe it would be useful to state that a beneficiary does not have appeal rights under these circumstances. Instead, we have revised the letter (attached) to clearly state that the appropriate action for the enrollee to take is to find another provider in the area to furnish these services and to contact the plan if assistance is needed. To further clarify, claim rejection or payment denial due to preclusion is not a coverage determination and therefore does not warrant appeal rights. However, the enrollee has the right to request a grievance if there is dissatisfaction due to a claim being rejected or payment denied because of a precluded provider.
Is a provider on the preclusion list a coverage request?
The issue of the provider being on the preclusion list is not a coverage request. Therefore, clinical appropriateness should not be reviewed, and, there would not be a reason for an authorization to be put in place for a Part D drug.
Is the MA preclusion list required for non-contracting providers?
Yes, effective January 1, 2020, the regulation will formally require application of the preclusion list to non-contracted MA providers. However, CMS stated in the preamble to CMS-4182-F that plans should begin applying these requirements, including beneficiary notification, to non-contracted providers as a best practice.
Does CMS require a sponsor to notify a prescriber of a beneficiary?
No. The regulation states that a sponsor must ensure reasonable efforts are made to notify the prescriber of a beneficiary who was sent a notice. CMS does not view reasonable efforts as including notifying these types of providers.
What is a Medicare MCMG?
The Medicare Communications and Marketing Guidelines (MCMG) discuss requirements applicable to all communication activities and materials, as well as additional requirements only applicable to marketing activities and materials. The beneficiary letter is designated as a communication material and as such, this means that all activities and materials are aimed at prospective and current enrollees, and are within the scope of the regulations at 42 C.F.R. Parts 417, 422, and 423.
How long do you have to notify HPMS of a denied claim?
In accordance with the November 2, 2018 HPMS guidance memo, the beneficiary should be notified “as soon as possible but not later than 30 days from the posting of the list” and the beneficiary should have “at least 60 days’ advance notice” before a plan denies payment/rejects claims associated with a precluded provider. Thus, a plan may provide a beneficiary with more than 60 days’ notice, and if a plan does so, the plan should not deny payments/reject claims earlier than 90 days after publication of the associated Preclusion List. This period will allow the beneficiary at least
Can a CMS plan access the preclusion list?
Only approved CMS healthcare plans, with a valid Health Plan ID, can gain access to the Preclusion List. For instructions on how to access the Preclusion List visit
Do Medicare plans have to update the preclusion list?
Yes. As stated in the November 2, 2018 HPMS guidance memo, “CMS recommends that Medicare plans and Part D plans follow the same process for monthly updates to the Preclusion List as they did for the initial list. The plans will have 30 days to review the Preclusion List for updates and should notify the impacted enrollees as soon as possible, but no later than 30 days from the posting of the updated list.” However, since the subsequent Preclusion Lists will be full files, Medicare plans and Part D plans are not required to resend monthly notifies to the same beneficiaries when the same precluded provider appears on the monthly list.
Does CMS base preclusion date on OIG?
CMS will not base the preclusion date on the OIG exclusion date. The preclusion date is based onthe publication date. The Preclusion List and exclusion file overlap in the sense that excludedproviders will be on the Preclusion List if they meet the following criteria:
Do MA plans have to contract with pharmacies?
As stated in the November 2, 2018 HPMS guidance memo, “Part D plans are also expected toremove any precluded pharmacy from their network as soon as possible.” MA plans are not requiredto contract with pharmacies.
Is a beneficiary notice required for a 2018 HPMS guidance memo?
Yes. The beneficiary notice attached to the November 2, 2018 HPMS guidance memo is a sample notice. Plans are not required to use this version for the required beneficiary notice, however, the letters should include the information specified in the sample notice.
What is a preclusion list?
Simply stated, the CMS preclusion list is a register of all health care providers, suppliers, and prescribers who are precluded from receiving reimbursement for Medicare Advantage items and services or Part D drugs that are provided or prescribed to Medicare beneficiaries. CMS has established the preclusion list in an effort to better ensure patient safety and to protect the integrity of the Medicare Trust Funds from the actions of providers and prescribers that have been identified as “bad actors.”
How long is a provider on the preclusion list?
If a provider, supplier, or prescriber is placed in the CMS preclusion list due to a felony conviction, the length of the preclusion will remain in effect for a 10-year period, beginning on the date of the felony conviction, unless CMS determines that a shorter time period is warranted (effective January 1, 2020).
What is the purpose of the exclusion and preclusion regulations?
While based on completely different statutes, both the exclusion and preclusion regulations are intended to protect that safety of Medicare, Medicare and Federal health care beneficiaries AND help safeguard the financial integrity of Federal and State health care programs.
Does Medicare have a preclusion list?
Unfortunately, Medicare providers and suppliers do not have access to the CMS Preclusion List. Only CMS approved Medicare Advantage (Part C) and Part D payor plans have with a valid Health Plan ID been granted access to the preclusion database.
Can an excluded party work for a participating provider?
Moreover, an excluded party cannot work for a participating provider. Nor can an excluded party serve as an agent, contractor, ...
1. Overview
The OIG Exclusion List is a registry of individuals and entities that have been excluded from participation in Federal health care programs. Exclusion may be mandatory in nature or permissive, depending based on the underlying adverse action.
2. Purpose
If a health care provider, supplier, or other entity is on the OIG Exclusion LIST, the excluded party cannot provide care or services to Medicare and / or Medicaid beneficiaries. Nor can the excluded party work for a participating provider or serve as an agent, contractor, or vendor for participating provider or supplier.
3. Who Has Access?
The OIG Exlcusion List is available to the public. Providers must also review approximately 60 State Medicaid exclusion databases.
4. Size of the Database
As of April, 2021, approximately 70,000 individuals and entities are on the OIG Exclusion List. An additional 150,000 parties are listed on State Medicaid exclusion lists.
5. Potential Penalties
The improper employment or engagement of an individual on the OIG Exclusion List can result in overpayments, significant Civil Monetary Penalties and a variety of other administrative adverse actions.
6. Conclusion
It is our hope that the above article helped you distinguish the differences between the OIG Exclusion List vs. CMS Preclusion List. However, we at Exclusion Screening understand that fulfilling your screening requirements can be difficult or impossible to manage on your own.
What are permissive exclusions?
Under permissive exclusions, the OIG has discretion to exclude individuals for: 1 misdemeanor convictions relating to health care fraud other than Medicare or a State health program; 2 misdemeanor convictions relating to the unlawful manufacture, distribution, prescription of controlled substances; 3 suspension, revocation or surrender of a license to provide health care for reasons bearing on professional competence, professional performance or a financial integrity provision of 4 unnecessary or substandard services; 5 defaulting on health education loan or scholarship obligations.
How long is a mandatory exclusion?
Mandatory exclusions are for a minimum 5-year period and do not come off automatically but requires a written request be provided for that. If the OIG proceeds with the exclusion, a Notice of Exclusion will be issued.
What is fraud in Medicare?
fraud as well as any other offenses related to the delivery of items or services under Medicare/Medicaid or other State programs; felony convictions related to unlawful manufacture, distribution, prescription or dispensing of controlled substances.
What is prescription fraud?
prescription fraud or; any criminal offense regarding Medicare or Medicaid or; withholding of services to Medicare or Medicaid patients; your license is: placed on suspension or; revoked or; surrendered for reasons bearing on certain enumerated circumstances.
