C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart H—Appeals Under the Medicare Part B Program

42 C.F.R. § 405.809

Reinstatement of provider or supplier billing privileges following corrective action

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(a) General rule. A provider or supplier—

(1) May only submit a corrective action plan for a revocation for noncompliance under § 424.535(a)(1) of this chapter; and

(2) Subject to paragraph (a)(1) of this section, has only one opportunity to correct all deficiencies that served as the basis of its revocation through a corrective action plan.

(b) Review of a corrective action plan. Subject to paragraph (a)(1) of this section, CMS or its contractor reviews a submitted corrective action plan and does either of the following:

(1) Reinstates the provider or supplier's billing privileges if the provider or supplier provides sufficient evidence to CMS or its contractor that it has complied fully with the Medicare requirements, in which case—

(i) The effective date of the reinstatement is based on the date the provider or supplier is in compliance with all Medicare requirements; and

(ii) CMS or its contractor may pay for services furnished on or after the effective date of the reinstatement.

(2) Refuses to reinstate a provider or supplier's billing privileges. The refusal of CMS or its contractor to reinstate a provider or supplier's billing privileges based on a corrective action plan is not an initial determination under part 498 of this chapter.

[79 FR 72530, Dec. 5, 2014]
Notes of Decisions
Cited in 6 cases, 1989–2019 · leading case: Zille Shah v. Alex Azar, Sec'y, HHS, 920 F.3d 987 (5th Cir. 2019).
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Zille Shah v. Alex Azar, Sec'y, HHS, 920 F.3d 987 (5th Cir. 2019). “26 42 C.F.R. § 405.809 (b). 27 Id. ; 42 C.F.”
Isaacs v. Bowen, 865 F.2d 468 (2d Cir. 1989). “See 42 C.F.R. § 405.809 . The carrier must then conduct an internal paper review of its own determination.”
Michigan Ass'n of Indep. Clinical Labs. v. Shalala, 52 F.3d 1340 (6th Cir. 1994). · cites it 2× “42 C.F.R. §§ 405.809 -.810 (1994). 3. If the supplier remains unsatisfied and the amount in controversy is at least $100, the supplier may request a carrier hearing within six months of the review determination.”
Erringer v. Thompson, 189 F. Supp. 2d 984 (D. Ariz. 2001). “§ 1395hh; (3) violation of the Due Process Clause of the United States Constitution; and (4) violation of two provisions of the Medicare regulations setting standards for administrative appeals, 42 C.F.R. §§ 405.809 , and 405.811. Plaintiffs seek: (T) a declaratory judgment that…”
Native Angels Home Health, Inc. v. Burwell, 123 F. Supp. 3d 775 (E.D.N.C. 2015). “42 C.F.R. § 405.809 . In addition, plaintiff was afforded the opportunity to take advantage of an expedited administrative appeal process, which culminates in judicial review, after its billing privileges had been rescinded.”
Advanced Med. Tech., Inc. v. Shalala, 974 F. Supp. 417 (D.N.J. 1997). “807 , including an opportunity to present further written evidence, 42 C.F.R. § 405.809 . Third, an appeal from the review determination is perfected by a request for a “fair hearing” before a carrier appointed hearing officer.”
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