C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 424—CONDITIONS FOR MEDICARE PAYMENT › Subpart P—Requirements for Establishing and Maintaining Medicare Billing Privileges

42 C.F.R. § 424.545

Provider and supplier appeal rights

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(a) General. A prospective provider or supplier that is denied enrollment in the Medicare program, or a provider or supplier whose Medicare enrollment has been revoked may appeal CMS' decision in accordance with part 498, subpart A of this chapter.

(1) Appeals resulting in the termination of a provider agreement. (i) When revocation of billing privileges also results in the termination of a corresponding provider agreement, the provider may appeal CMS' decision in accordance with part 498 of this chapter with the final decision of the appeal applying to both the billing privileges and the provider agreement.

(ii) When a provider appeals the revocation of billing privileges and the termination of its provider agreement, there will be one appeals process which will address both matters. The appeal procedures for revocation of Medicare billing privileges will apply.

(2) Payment of unpaid claims. Payment is not made during the appeals process. If the provider or supplier is successful in overturning a denial or revocation, unpaid claims for services furnished during the overturned period may be resubmitted.

(b) A provider or supplier whose billing privileges are deactivated may file a rebuttal in accordance with § 424.546 of this chapter.

(c) The provider or supplier must be able to demonstrate that it meets the enrollment requirements and it must be able to make available any documents and records that support the provisions of this regulation and the Medicare enrollment application if requested by CMS or its agents.

[71 FR 20776, Apr. 21, 2006, as amended at 73 FR 36461, June 27, 2008; 86 FR 65683, Nov. 19, 2021]
Notes of Decisions
Cited in 3 cases (1 in the last 5 years), 2014–2022 · leading case: Arriva Med. LLC v. United States Dep't of Health & Human Servs., 239 F. Supp. 3d 266 (D.D.C. 2017).
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Arriva Med. LLC v. United States Dep't of Health & Human Servs., 239 F. Supp. 3d 266 (D.D.C. 2017). · cites it 4× “Where (as here) post-administrative-review payments are available if a supplier succeeds, see 42 C.F.R. § 424.545 (a)(2), Eldridge jurisdiction is limited to those instances where “an erroneous termination would damage [the plaintiff] in a way not recompensable *280 through…”
Pawlowski v. Becerra (W.D.N.Y. 2022). “See 42 C.F.R. § 424.545 (a)(2). And similar allegations that a plaintiff “w[ould] go out of business before the appeals process is completed” have been deemed insufficient to deem exhaustion waived based on irreparable harm.”
Home Health Care Plus, Inc. v. Burwell, 85 F. Supp. 3d 866 (N.D. Tex. 2014). “Plaintiff claims that the 90 days to over a year appeal process available under 42 C.F.R. § 424.545 is futile because an analogous case received an unfavorable decision when the fact finder concluded that the provider’s nonoperational determination is made at the address…”
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