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Preclusion List

CMS published CMS-4182-F on April 16, 2018, which rescinds the enrollment requirement for providers who prescribe drugs to patients enrolled in Medicare Part D and for network providers and suppliers that furnish health care items or services to a Medicare beneficiary who receives his or her Medicare benefit through a Medicare Advantage (MA) organization.

As an alternative, the regulation creates a Preclusion List that will consist of individuals and entities that fall within either of the following categories:

(1) Are currently revoked from Medicare, are under an active reenrollment bar, and CMS determines that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program; or

(2) Have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program.

Will happens if I am on the Preclusion List?

Providers and suppliers will receive a letter from their Medicare Administrative Contractors (MACs) of their inclusion on the Preclusion List. The letter will be sent to their Provider Enrollment Chain and Ownership System (PECOS) correspondence address or National Plan and Provider Enumeration System (NPPES) mailing address and will contain the reason for the inclusion, the time period for which the provider or supplier is precluded, and their appeal applicable rights.

CMS will make the Preclusion List available to Part D sponsors and the MA plans. Effective January 1, 2019, Part D sponsors will be required to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List and MA plans will be required to deny payment for a health care item or service furnished by an individual or entity on the Preclusion List.

Downloads

Preclusion List FAQs

CMS-4182 Final Rule

CMS-4159 Final Rule [PDF, 887KB]

CMS-6107 Interim final rule with comment (FC)

Online Enrollment File

Quick Reference Guide for CMS Preclusion List

CMS Preclusion List File Layout

CMS Preclusion List Sample File

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