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Preclusion List

Question  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.
 

Question  Why was the list created?

  • To replace the Medicare Advantage (MA) and prescriber enrollment requirements.
  • To ensure patient protections and safety and to protect the Trust Funds from prescribers and providers
    identified as bad actors.

Question  Who is on the list?

Individuals or entities who meet the following criteria:

Are currently revoked from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program.

OR

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.

What happens if I'm on the Preclusion List?

Illustrated image of an envelope with letter

You will receive an email and letter from CMS/Medicare Administrative Contractors (MAC) in advance of your inclusion on the Preclusion List.

Illustrated image of an envelope being sent

The email and letter will be sent to your Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing

Illustrated image of two letters

The letter will contain the reason you are precluded, the effective date of your preclusion, and your applicable rights to appeal.


What's the Impact?

Effective Date April 1st 2019

CMS will make the Preclusion List available to Part D sponsors and the MA plans beginning JANUARY 1, 2019. EFFECTIVE APRIL 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.
  • 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.

Want to learn more?

Need more information?

Please contact providerenrollment@cms.hhs.gov

.