CMS has a Preclusion List effective for claims with dates of service on or after April 1, 2019. The Preclusion List applies to both Medicare Advantage plans as well as Part D plans. It is comprised of a list of prescribers and individuals or entities who:
- Are 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
- Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent possible if they had been enrolled in Medicare, and that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program
- Have been convicted of a felony under federal or state law within the previous 10 years and that CMS deems detrimental to the best interests of the Medicare program
Providers receive a letter from CMS notifying them of their placement on the Preclusion List. They have the opportunity to appeal with CMS before the preclusion is effective. There is no opportunity to appeal with Peoples Health. CMS updates the Preclusion List monthly and notifies Medicare Advantage and Part D plans of the claim rejection date, which is the date upon which Peoples Health will reject or deny a provider’s claims due to precluded status. Once the claim-rejection date is effective, a precluded provider’s claims will no longer be paid, pharmacy claims will be rejected, and the provider will be terminated from the Peoples Health network. Additionally, the precluded provider must hold Medicare beneficiaries harmless from financial liability for services provided on or after the claim rejection date.
As a contracted provider of Peoples Health, you must ensure that payments for health care services or items are not made to individuals or entities on the Preclusion List, including employed or contracted individuals or entities.
Further, you and/or your medical group, as applicable, and Peoples Health agree to ensure that the following obligations are agreed to and/or performed with respect to precluded providers:
- Peoples Health and you/your group agree to ensure that a Peoples Health enrollee does not have any financial liability for services, items, or drugs furnished, ordered, or prescribed to him or her by an individual or entity on the preclusion list, as defined and described in 42 C FR § 422.2 and 422.222. [422.504(g)(1))iv)]
- Peoples Health and you/your group agree that after the expiration of the 60-day period specified in 42 C FR §422.222:
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- A provider, including you/your group, will no longer be eligible for payment from Peoples Health and will be prohibited from pursuing payment from the Peoples Health enrollee as stipulated by the terms of the contract between CMS and Peoples Health per 42 C FR §422.504(g)(1)(iv)
- A provider, including you/your group, will hold financial liability for services, items, and drugs that are furnished, ordered, or prescribed after this 60-day period, at which point the provider will have already received notification of the preclusion. [422.504(g)(1)(v)]
For more information, visit www.cms.gov.