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Why Have You Received a Denial on Your Medicare Enrollment Application?

by George F. Indest III, J.D., M.P.A., LL.M. and Christopher E. Brown, J.D., 7.17.14

Was your Medicare enrollment application denied, and you can’t figure out why?

You may be surprised to learn that even the smallest punctuation error, such as a missing comma or period, could cause your Medicare application to be rejected. 

“The Centers for Medicare and Medicaid Services (CMS) will deny Medicare applications of physicians, medical groups, home health agencies (HHAs), pharmacies and durable medical equipment (DME) suppliers because the name on file with the National Plan & Provider Enumeration System (NPPES) is not the same legal business name as reported to the Internal Revenue Service (IRS). The use of punctuation marks and abbreviations in your name with NPPES could produce a no match in the CMS records. It is imperative when filling out the Medicare enrollment forms that you use the exact legal business name on file with the IRS.”

Other Reasons Why a Medicare Enrollment Application can be Denied

Some additional scenarios that can cause a provider’s application to be denied:

  1. The CMS-855 form or PECOS certification statement is unsigned – is undated – contains a copied or stamped signature; or for paper form CMS-855I and CMS-855O submissions, someone other than the physician or non-physician practitioner signed the form.
  2. The submitted paper application is an outdated version.
  3. The applicant failed to submit all of the forms needed to process a reassignment package within 15 calendar days of receipt.

                             (click here to see more reasons and read the full article)

Update All of Your Information with Medicare

If you are already a Medicare provider, I urge you to personally go into the PECOS and NPPES and print out a copy of the existing information to check it. If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately fix this. Everything should be consistent. All of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information as well.

Incorrect Information Could Lead to the Termination of Your Medicare Provider Number

The consequences of not checking your information on file are severe, and can include termination of your Medicare provider number and billing privileges. The effect of this termination includes:

  • You are prohibited from reapplying to Medicare for at least two years.
  • You may have to pay back any money received from the Medicare program since the effective date of the termination (often many months prior to the notification letter).
  • You may no longer contract with Medicare or anyone who does.
  • You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.

                          (click here to read other results of termination and the full article)

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area.

Christopher E. Brown, J.D., is an attorney with The Health Law Firm, which has a national practice.



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